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Measure Index
Measure Index
The National Quality Measures Clearinghouse™ (NQMC),
sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of
Health and Human Services, provides a Measure Index, a complete list of measure
summaries available through the NQMC Web site. The listing is organized alphabetically,
by measure developer and/or submitter name (measure developers and submitters include
both organizations and individuals).
The NQMC Web site is updated weekly. The NQMC Update Service notifies you via
e-mail when new features and measures become available at the NQMC Web site. To receive e-mail
notifications, subscribe to the
NQMC Update Service.
The National Quality Measures Clearinghouse™ currently contains 1918 individual measure summaries.
Accreditation Association for Ambulatory Health Care Institute for Quality Improvement(2)
Intra-procedure colonoscopy complication rate: percentage of patients who developed one or more intra-procedure complications.
Patient understanding of colonoscopy procedure: percentage of patients answering "yes" to the post-procedure telephone interview question "Did you understand why the procedure was being done and what was going to happen?".
Accreditation Association for Ambulatory Health Care Institute for Quality Improvement, Performance Measurement Initiative, Colonoscopy Work Group(2)
Intra-procedure colonoscopy complication rate: percentage of patients who developed one or more intra-procedure complications.
Patient understanding of colonoscopy procedure: percentage of patients answering "yes" to the post-procedure telephone interview question "Did you understand why the procedure was being done and what was going to happen?".
Agency for Healthcare Research and Quality(161)
Abdominal aortic aneurysm (AAA) repair: mortality rate. [NQMC Update Pending]
Abdominal aortic aneurysm (AAA) repair: volume. [NQMC Update Pending]
Accidental puncture or laceration (area-level): rate per 100,000 population. [NQMC Update Pending]
Accidental puncture or laceration (provider level): rate per 1,000 discharges. [NQMC Update Pending]
Accidental puncture or laceration: rate per 1,000 eligible discharges. [NQMC Update Pending]
Acute myocardial infarction (AMI): mortality rate, without transfer cases. [NQMC Update Pending]
Acute myocardial infarction (AMI): mortality rate. [NQMC Update Pending]
Acute stroke: mortality rate. [NQMC Update Pending]
Adult asthma: hospital admission rate. [NQMC Update Pending]
Asthma admission rate (area level): rate per 100,000 population. [NQMC Update Pending]
Bacterial pneumonia: hospital admission rate. [NQMC Update Pending]
Behavioral health care patients' experiences: percentage of adult patients who rated how much improvement they perceived in themselves.
Behavioral health care patients' experiences: percentage of adult patients who reported how much of a problem they had getting treatment and information from their health plan or managed behavior health organization.
Behavioral health care patients' experiences: percentage of adult patients who reported how much they were helped by the counseling or treatment they received.
Behavioral health care patients' experiences: percentage of adult patients who reported how often their clinicians communicated well.
Behavioral health care patients' experiences: percentage of adult patients who reported how often they get treatment quickly.
Behavioral health care patients' experiences: percentage of adult patients who reported how often they were seen within 15 minutes of their appointment.
Behavioral health care patients' experiences: percentage of adult patients who reported whether anyone shared information regarding their counseling or treatment that should have been kept private.
Behavioral health care patients' experiences: percentage of adult patients who reported whether someone talked to them about including family or friends in their counseling or treatment.
Behavioral health care patients' experiences: percentage of adult patients who reported whether the care they received was responsive to their cultural needs.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they felt they could refuse a specific type of medicine or treatment.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given enough information to manage their condition.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given information about patient rights.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were provided information about treatment options.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about medication side effects.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about other ways to receive treatment after their benefits were used up.
Behavioral health care patients' satisfaction: adult patients' overall rating of the counseling or treatment they received.
Behavioral health care patients' satisfaction: adult patients' overall rating of their health plan for counseling or treatment.
Birth trauma -- injury to neonate: rate per 1,000 liveborn births. [NQMC Update Pending]
Carotid endarterectomy (CEA): mortality rate. [NQMC Update Pending]
Carotid endarterectomy (CEA): volume. [NQMC Update Pending]
Cholecystitis/cholelithiasis: laparoscopic cholecystectomy rate. [NQMC Update Pending]
Chronic obstructive pulmonary disease (COPD): hospital admission rate. [NQMC Update Pending]
Congestive heart failure (CHF): hospital admission rate. [NQMC Update Pending]
Congestive heart failure (CHF): mortality rate. [NQMC Update Pending]
Coronary artery bypass graft (CABG): volume. [NQMC Update Pending]
Coronary artery disease: angina without procedure hospital admission rate. [NQMC Update Pending]
Coronary artery disease: bilateral cardiac catheterization rate. [NQMC Update Pending]
Coronary artery disease: coronary artery bypass graft (CABG) area rate. [NQMC Update Pending]
Coronary artery disease: coronary artery bypass graft (CABG) mortality rate. [NQMC Update Pending]
Coronary artery disease: percutaneous transluminal coronary angioplasty (PTCA) area rate. [NQMC Update Pending]
Craniotomy: mortality rate. [NQMC Update Pending]
Death among surgical inpatients with serious treatable complications: deaths per 1,000 discharges. [NQMC Update Pending]
Death in low-mortality DRGs: in-hospital deaths per 1,000 discharges. [NQMC Update Pending]
Decubitus ulcer: rate per 1,000 discharges. [NQMC Update Pending]
Decubitus ulcer: rate per 1,000 eligible admissions. [NQMC Update Pending]
Dehydration: hospital admission rate. [NQMC Update Pending]
Diabetes mellitus: hospital admission rate for long-term complications. [NQMC Update Pending]
Diabetes mellitus: hospital admission rate for short-term complications. [NQMC Update Pending]
Diabetes mellitus: hospital admission rate for uncontrolled diabetes. [NQMC Update Pending]
Diabetes mellitus: lower-extremity amputation rate. [NQMC Update Pending]
Diabetes short-term complications admission rate (area level): rate per 100,000 population. [NQMC Update Pending]
Esophageal cancer: esophageal resection mortality rate. [NQMC Update Pending]
Esophageal resection: volume. [NQMC Update Pending]
Foreign body left during procedure (area level): discharges per 100,000 population. [NQMC Update Pending]
Gastroenteritis admission rate (area level): rate per 100,000 population. [NQMC Update Pending]
Gastrointestinal (GI) hemorrhage: mortality rate. [NQMC Update Pending]
Health plan members' experiences: percentage of adult health plan members who reported how often it was easy for them to get needed care.
Health plan members' experiences: percentage of adult health plan members who reported how often their personal doctor communicated well.
Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.
Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan information and customer service.
Health plan members' experiences: percentage of parents or guardians who reported how often it was easy for them to get needed care for their enrolled child.
Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get prescription medicines for their enrolled children with chronic conditions through their health plan.
Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get specialized services for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child got care quickly.
Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child's personal doctor communicated well.
Health plan members' experiences: percentage of parents or guardians who reported how often they were satisfied with their enrolled child's health plan information and customer service.
Health plan members' experiences: percentage of parents or guardians who reported their experiences with getting needed information about their children's care for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported their experiences with shared decision-making for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported their experiences with their children's personal doctor or nurse for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported they received assistance with coordination of care and services for their enrolled children with chronic conditions.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their health care.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their health plan.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their personal doctor.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their specialist.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health care.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health plan.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's personal doctor.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's specialist.
Hip fracture: mortality rate. [NQMC Update Pending]
Hip osteoarthrosis: hip replacement mortality rate. [NQMC Update Pending]
Hospital inpatients' experiences: adult inpatients' ratings of this hospital.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often the area around their room was quiet at night.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff communicated well about medications.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff was responsive to their needs.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their doctors communicated well.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their nurses communicated well.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their pain was controlled.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their room and bathroom were kept clean.
Hospital inpatients' experiences: percentage of adult inpatients who reported whether they were provided specific discharge information.
Hospital inpatients' experiences: percentage of adult inpatients who reported whether they would recommend this hospital to their friends and family.
Hypertension: hospital admission rate. [NQMC Update Pending]
Hysterectomy: hysterectomy area rate. [NQMC Update Pending]
Iatrogenic pneumothorax (area-level): rate per 100,000 population. [NQMC Update Pending]
Iatrogenic pneumothorax (provider-level): rate per 1,000 discharges. [NQMC Update Pending]
Iatrogenic pneumothorax in non-neonates: rate per 1,000 eligible admissions. [NQMC Update Pending]
In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often their nephrologist cared and communicated well.
In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often they were satisfied with the quality of dialysis center care and operations.
In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported whether specified information was provided to them.
In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center staff.
In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center.
In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their kidney doctors.
Incidental appendectomy: incidental appendectomy among the elderly rate. [NQMC Update Pending]
Laminectomy or spinal fusion: laminectomy or spinal fusion area rate. [NQMC Update Pending]
Low birth weight: rate of infants with low birth weight. [NQMC Update Pending]
Maternity care: Cesarean delivery rate. [NQMC Update Pending]
Maternity care: primary Cesarean delivery rate. [NQMC Update Pending]
Maternity care: vaginal birth after Cesarean (VBAC) rate, all. [NQMC Update Pending]
Maternity care: vaginal birth after Cesarean (VBAC) rate, uncomplicated. [NQMC Update Pending]
Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 instrument-assisted vaginal deliveries. [NQMC Update Pending]
Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 vaginal deliveries without instrument assistance. [NQMC Update Pending]
Pancreatic cancer: pancreatic resection mortality rate. [NQMC Update Pending]
Pancreatic resection: volume. [NQMC Update Pending]
Patients' experiences: percentage of adult primary care patients who reported how often it was easy for them to get appointments and needed care.
Patients' experiences: percentage of adult primary care patients who reported how often their doctor's office followed up on results for blood tests, x-rays or any other tests ordered.
Patients' experiences: percentage of adult primary care patients who reported how often their doctor's office staff was courteous and helpful.
Patients' experiences: percentage of adult primary care patients who reported how often their doctors communicated well.
Patients' experiences: percentage of adult specialty care patients who reported how often it was easy for them to get appointments and needed care.
Patients' experiences: percentage of adult specialty care patients who reported how often their doctor's office followed up on results for blood tests, x-rays or any other tests ordered.
Patients' experiences: percentage of adult specialty care patients who reported how often their doctor's office staff was courteous and helpful.
Patients' experiences: percentage of adult specialty care patients who reported how often their doctors communicated well.
Patients' experiences: percentage of parents/guardians who reported how often it was easy for them to get appointments and needed care for their child.
Patients' experiences: percentage of parents/guardians who reported how often it was easy for them to get appointments and needed care for their child.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor communicated well.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor communicated well.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office followed up on results for blood tests, x-rays or any other tests ordered.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office followed up on results for blood tests, x-rays or any other tests ordered.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office staff was courteous and helpful.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office staff was courteous and helpful.
Patients' experiences: percentage of parents/guardians who reported whether their child's doctor addressed their child's growth and development.
Patients' experiences: percentage of parents/guardians who reported whether their child's doctor gave advice on keeping their child safe and healthy.
Patients' satisfaction with care: adult primary care patient's overall rating of their doctor.
Patients' satisfaction with care: adult specialty care patient's overall rating of their doctor.
Patients' satisfaction with care: parent's/guardian's overall rating of their child's doctor.
Patients' satisfaction with care: parent's/guardian's overall rating of their child's doctor.
Pediatric heart surgery mortality: number of in-hospital deaths in patients undergoing surgery for congenital heart disease per 1,000 patients. [NQMC Update Pending]
Pediatric heart surgery: volume. [NQMC Update Pending]
Percutaneous transluminal coronary angioplasty (PTCA): mortality rate. [NQMC Update Pending]
Percutaneous transluminal coronary angioplasty (PTCA): volume. [NQMC Update Pending]
Perforated appendix admission rate (area level): number of patients admitted for perforated appendix per 100 admissions for appendicitis within an area. [NQMC Update Pending]
Perforated appendix: hospital admission rate. [NQMC Update Pending]
Pneumonia: mortality rate. [NQMC Update Pending]
Postoperative hemorrhage and hematoma: rate per 1,000 eligible admissions. [NQMC Update Pending]
Postoperative hemorrhage or hematoma requiring a procedure (area-level): rate per 100,000 population. [NQMC Update Pending]
Postoperative hemorrhage or hematoma requiring a procedure (provider level): rate per 1,000 surgical discharges. [NQMC Update Pending]
Postoperative hip fracture: rate per 1,000 surgical discharges. [NQMC Update Pending]
Postoperative physiologic and metabolic derangement: rate per 1,000 elective surgical discharges with an operating room procedure. [NQMC Update Pending]
Postoperative pulmonary embolism or deep vein thrombosis: rate per 1,000 surgical discharges with an operating room procedure. [NQMC Update Pending]
Postoperative respiratory failure: rate per 1,000 elective surgical discharges with an operating room procedure. [NQMC Update Pending]
Postoperative respiratory failure: rate per 1,000 eligible admissions. [NQMC Update Pending]
Postoperative sepsis: rate per 1,000 elective surgery discharges with an operating room procedure and a length of stay of 4 days or more. [NQMC Update Pending]
Postoperative sepsis: rate per 1,000 eligible admissions. [NQMC Update Pending]
Postoperative wound dehiscence (area-level): rate of reclosure of post operative disruption of abdominal wall per 100,000 population. [NQMC Update Pending]
Postoperative wound dehiscence (provider-level): rate of reclosure of postoperative disruption of abdominal wall per 1,000 cases of abdominopelvic surgery. [NQMC Update Pending]
Postoperative wound dehiscence: number of abdominopelvic surgery patients with disruption of abdominal wall per 1,000 eligible admissions. [NQMC Update Pending]
Selected infection due to medical care: rate per 1,000 eligible admissions. [NQMC Update Pending]
Selected infections due to medical care (area-level): rate per 100,000 population. [NQMC Update Pending]
Selected infections due to medical care (provider level): rate per 1,000 discharges. [NQMC Update Pending]
Transfusion reaction (area-level): rate per 100,000 population. [NQMC Update Pending]
Urinary tract infection (UTI) admission rate (area level): rate per 100,000 population. [NQMC Update Pending]
Urinary tract infection: hospital admission rate. [NQMC Update Pending]
Ambulatory Surgery Center (ASC) Quality Collaboration(6)
Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions experiencing a burn prior to discharge.
Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions experiencing a fall within the confines of the ASC.
Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions requiring a hospital transfer or hospital admission upon discharge from the ASC.
Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions who experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant.
Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions with an order for a prophylactic IV antibiotic for prevention of surgical site infection, who receive the prophylactic antibiotic on time.
Ambulatory surgery: percentage of ambulatory surgery center (ASC) admissions with surgical site hair removal with clippers or depilatory cream.
American Academy of Dermatology(4)
Melanoma: percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma who were entered into a recall system with the date for the next complete physical skin exam specified, at least once within the 12 month reporting period.
Melanoma: percentage of patients, regardless of age, with a new diagnosis of melanoma or a history of melanoma who received all of the following aspects of care within the 12 month reporting period: (1) patient was asked about new and changing moles AND (2) patient received a complete physical skin examination AND (3) patient was counseled to perform a monthly self skin examination.
Melanoma: percentage of patients, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.
Melanoma: percentage of patients, regardless of age, with stage 0 or IA melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered.
American Academy of Family Physicians(10)
Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.
Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.
Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.
Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis for whom an appropriate oral rehydration solution was recommended.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had documentation of hydration status.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had weight measurement recorded.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis whose parent/caregiver received education on diet and when to contact the physician.
American Academy of Neurology(8)
Stroke and stroke rehabilitation: percentage of final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the hospital for patients aged 18 years and older with either a diagnosis of ischemic stroke or TIA or intracranial hemorrhage or at least one documented symptom consistent with ischemic stroke or TIA or intracranial hemorrhage that include documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke who did not receive intravenous unfractionated heparin.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for tissue plasminogen activator (t-PA) administration.
American Academy of Ophthalmology(10)
Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months.
Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes regarding the findings of the macular or fundus exam at least once within 12 months.
Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma or their caregiver who were counseled within 12 months about 1) the potential impact of glaucoma on their visual functioning and quality of life, and 2) the importance of treatment adherence.
Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma who have an optic nerve head evaluation during one or more office visits within 12 months.
Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level a plan of care was documented within 12 months.
Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had
cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence.
Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.
Eye care: percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL placement who received a comprehensive preoperative assessment of 1) dilated fundus exam; 2) axial length, corneal keratometry measurement, and method of IOL power calculation; and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL placement within 12 months prior to cataract surgery.
Eye care: percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the AREDS formation for preventing progression of AMD.
Eye care: percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage, AND the level of macular degeneration severity during one or more office visits within 12 months.
American Academy of Orthopaedic Surgeons(13)
Osteoarthritis: percentage of patient visits during which an anti-inflammatory agent or analgesic was considered.
Osteoarthritis: percentage of patient visits during which gastrointestinal (GI) prophylaxis was considered.
Osteoarthritis: percentage of patient visits during which therapeutic exercise for the knee (therapeutic exercise instructed or physical therapy prescribed) was considered.
Osteoarthritis: percentage of patient visits with assessment for function and pain.
Osteoarthritis: percentage of patient visits with assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications.
Osteoarthritis: percentage of patients for whom a physical examination of the involved joint was performed during the initial visit.
Osteoarthritis: percentage of patients on prescribed or over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) who were assessed for gastrointestinal (GI)/renal risk factors.
Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.
Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.
Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.
Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.
American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) Foundation(8)
Acute otitis externa (AOE): percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with assessment for auricular or periauricular pain.
Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.
Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations.
Otitis media with effusion (OME): percentage of patient visits for those patients aged 2 months through 12 years with a diagnosis of OME with assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry.
Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion who had a hearing test performed within 6 months prior to tympanostomy tube insertion.
Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.
Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids.
Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed/recommended either antihistamines or decongestants.
American Academy of Pediatrics(4)
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis for whom an appropriate oral rehydration solution was recommended.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had documentation of hydration status.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had weight measurement recorded.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis whose parent/caregiver received education on diet and when to contact the physician.
American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association(15)
Cardiac rehabilitation: percentage of cardiac rehabilitation program(s) in the healthcare system that meet the specified performance measure criteria for communication with healthcare providers.
Cardiac rehabilitation: percentage of cardiac rehabilitation programs in the health system that meet this specified performance measure criteria for monitoring response to therapy and documenting program effectiveness.
Cardiac rehabilitation: percentage of cardiac rehabilitation programs in the healthcare system that meet specified structure-based performance measure criteria.
Cardiac rehabilitation: percentage of cardiac rehabilitation programs in the healthcare system that meet the specified performance measure criteria for assessment of risk for adverse cardiovascular events.
Cardiac rehabilitation: percentage of eligible inpatients with a qualifying event/diagnosis who have been referred to an outpatient cardiac rehabilitation program prior to hospital discharge or have a documented medical or patient-centered reason why such a referral was not made.
Cardiac rehabilitation: percentage of patients in an outpatient clinical practice who have had a qualifying event/diagnosis during the previous 12 months, who have been referred to an outpatient cardiac rehabilitation program.
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for adherence to preventive medications.
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for assessment of exercise capacity.
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for assessment of weight management.
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for blood pressure control.
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for depression.
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for diabetes mellitus or impaired fasting glucose.
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for lipid control.
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for physical activity habits.
Cardiac rehabilitation: percentage of patients in the healthcare system's cardiac rehabilitation program(s) who meet the specified performance measure criteria for tobacco use.
American Association of Clinical Endocrinologists(6)
Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.
Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.
Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.
Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.
American College of Cardiology(26)
Atrial fibrillation (AF) and atrial flutter: percentage of calendar months during the reporting year during which patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter, receiving warfarin therapy, have at least one INR measurement made.
Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period.
Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter with an assessment of all of the specified thromboembolic risk factors documented.
Chronic stable coronary artery disease (CAD): percentage of patients evaluated for both level of activity and anginal symptoms during one or more office visits.
Chronic stable coronary artery disease (CAD): percentage of patients identified as cigarette smokers who received a smoking cessation intervention.
Chronic stable coronary artery disease (CAD): percentage of patients queried one or more times about cigarette smoking.
Chronic stable coronary artery disease (CAD): percentage of patients who also have diabetes and/or left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.
Chronic stable coronary artery disease (CAD): percentage of patients who had a blood pressure measurement during the last office visit.
Chronic stable coronary artery disease (CAD): percentage of patients who received at least one lipid profile (or ALL component tests).
Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed antiplatelet therapy.
Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed lipid lowering therapy.
Chronic stable coronary artery disease (CAD): percentage of patients who were screened for diabetes.
Chronic stable coronary artery disease (CAD): percentage of patients with prior myocardial infarction (MI) who were prescribed beta-blocker therapy.
Heart failure: percentage of patient visits with assessment of activity level for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with assessment of clinical signs of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with assessment of clinical symptoms of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with blood pressure measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with weight measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy.
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy.
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure who were provided with patient education on disease management and health behavior changes during one or more visit(s).
Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years for whom initial laboratory testing was performed.
Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years with quantitative or qualitative results of left ventricular function (LVF) assessment recorded.
Hypertension: percentage of patient visits during which either systolic blood pressure is greater than or equal to 140 mm Hg or diastolic blood pressure is greater than or equal to 90 mm Hg, with documented plan of care for hypertension.
Hypertension: percentage of patient visits with blood pressure measurement recorded.
American College of Emergency Physicians(9)
Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed.
Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with mental status assessed.
Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed.
Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed.
Emergency medicine: percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG performed.
Emergency medicine: percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed.
Emergency medicine: percentage of patients, regardless of age, with an emergency department diagnosis of acute myocardial infarction who received fibrinolytic therapy and the fibrinolytic therapy was ordered by the physician within 20 minutes of performing the 12-lead ECG.
Emergency medicine: percentage of patients, regardless of age, with an emergency department diagnosis of STEMI or new LBBB on 12-lead ECG who received primary PCI who had documentation that the emergency physician initiated communication with the cardiology intervention service within 10 minutes of the diagnostic 12-lead ECG.
Emergency medicine: percentage of patients, regardless of age, with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay.
American College of Radiology(16)
Radiology: percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.
Radiology: percentage of final reports for CT examinations performed with documentation of use of appropriate radiation dose reduction devices OR manual techniques for appropriate moderation of exposure.
Radiology: percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time.
Radiology: percentage of final reports for screening mammograms that are classified "probably benign."
Radiology: percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.
Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the patient within 5 business days of exam interpretation.
Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the practice that manages the patient's on-going care within 3 business days of exam interpretation.
Radiology: percentage of patients undergoing screening mammograms whose assessment category (e.g., Mammography Quality Standards Act [MQSA], Breast Imaging Reporting and Data System [BI-RADS®], or FDA approved equivalent categories) is entered into an internal database that will, at a minimum, allow analysis of abnormal interpretation (recall) rate.
Stroke and stroke rehabilitation: percentage of final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the hospital for patients aged 18 years and older with either a diagnosis of ischemic stroke or TIA or intracranial hemorrhage or at least one documented symptom consistent with ischemic stroke or TIA or intracranial hemorrhage that include documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke who did not receive intravenous unfractionated heparin.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for tissue plasminogen activator (t-PA) administration.
American College of Rheumatology(10)
Gout: percentage of patients with gout receiving an initial prescription for allopurinol and have significant renal impairment whose initial daily allopurinol dose is less than 300 mg per day.
Gout: percentage of patients with gout started on urate-lowering therapy who have either a history of nephrolithiasis or significant renal insufficiency who are started on a xanthine oxidase inhibitor as the initial urate-lowering medication rather than a uricosuric agent.
Gout: percentage of patients with hyperuricemia and gouty arthritis who are offered treatment with a urate-lowering drug.
Gout: percentage of patients with tophaceous gout who are given an initial prescription for a urate-lowering medication and lack both significant renal impairment and peptic ulcer disease who had a prophylactic anti-inflammatory agent given concomitantly.
Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.
Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.
Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.
Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.
American College of Surgeons(6)
Perioperative care: percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics and who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time.
Perioperative care: percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics and who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 24 hours of surgical end time.
Perioperative care: percentage of patients undergoing procedures for which VTE prophylaxis is indicated in all patients who had an order for low-molecular weight heparin (LMWH), low-dose unfractionated heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time.
Perioperative care: percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first or second generation cephalosporin prophylactic antibiotic who had an order for cefazolin or cefuroxime for antimicrobial prophylaxis.
Perioperative care: percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics who have an order for an antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).
Perioperative care: percentage of surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of a prophylactic antibiotic has been initiated within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).
American Gastroenterological Association(3)
Endoscopy and polyp surveillance: percentage of final colonoscopy reports for patients aged 18 years and older that include documentation of all of the following: pre-procedure risk assessment; depth of insertion; quality of the bowel prep; complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; and recommendations for follow-up.
Endoscopy and polyp surveillance: percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp in previous colonoscopy findings who had a follow-up interval of 3 or more years since their last colonoscopy documented in the colonoscopy report.
Endoscopy and polyp surveillance: percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.
American Gastroenterological Association Institute(15)
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD who did not have a barium swallow test ordered.
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed.
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with a diagnosis of GERD or heartburn whose endoscopy report indicates a suspicion of Barrett's esophagus who had a forceps esophageal biopsy performed.
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding.
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with the diagnosis of GERD who have been prescribed chronic proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) therapy who received an assessment of their GERD symptoms within 12 months.
Hepatitis C: percentage of female patients aged 18 to 44 years and all men aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were counseled regarding contraception prior to the initiation of antiviral treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of antiviral treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at 12 weeks from initiation of antiviral treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were prescribed peginterferon and ribavirin therapy within the 12 month reporting period.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C with genotype 1 or 4 who are receiving antiviral treatment at week 24 for whom quantitative HCV RNA testing was performed at 24 weeks of treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial evaluation who had HCV RNA testing ordered or previously performed.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were counseled regarding the risks of alcohol consumption at least once within the 12 month reporting period.
American Geriatrics Society(9)
Geriatrics: percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence who were prescribed a medication to treat the urinary incontinence who had a trial of behavioral therapy documented.
Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months.
Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.
Geriatrics: percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.
Geriatrics: percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
Geriatrics: percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months.
Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.
Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months.
American Heart Association(26)
Atrial fibrillation (AF) and atrial flutter: percentage of calendar months during the reporting year during which patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter, receiving warfarin therapy, have at least one INR measurement made.
Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period.
Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter with an assessment of all of the specified thromboembolic risk factors documented.
Chronic stable coronary artery disease (CAD): percentage of patients evaluated for both level of activity and anginal symptoms during one or more office visits.
Chronic stable coronary artery disease (CAD): percentage of patients identified as cigarette smokers who received a smoking cessation intervention.
Chronic stable coronary artery disease (CAD): percentage of patients queried one or more times about cigarette smoking.
Chronic stable coronary artery disease (CAD): percentage of patients who also have diabetes and/or left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.
Chronic stable coronary artery disease (CAD): percentage of patients who had a blood pressure measurement during the last office visit.
Chronic stable coronary artery disease (CAD): percentage of patients who received at least one lipid profile (or ALL component tests).
Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed antiplatelet therapy.
Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed lipid lowering therapy.
Chronic stable coronary artery disease (CAD): percentage of patients who were screened for diabetes.
Chronic stable coronary artery disease (CAD): percentage of patients with prior myocardial infarction (MI) who were prescribed beta-blocker therapy.
Heart failure: percentage of patient visits with assessment of activity level for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with assessment of clinical signs of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with assessment of clinical symptoms of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with blood pressure measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with weight measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy.
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy.
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure who were provided with patient education on disease management and health behavior changes during one or more visit(s).
Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years for whom initial laboratory testing was performed.
Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years with quantitative or qualitative results of left ventricular function (LVF) assessment recorded.
Hypertension: percentage of patient visits during which either systolic blood pressure is greater than or equal to 140 mm Hg or diastolic blood pressure is greater than or equal to 90 mm Hg, with documented plan of care for hypertension.
Hypertension: percentage of patient visits with blood pressure measurement recorded.
American Medical Association on behalf of the AAFP, AAOS, AACE, American College of Rheumatology, The Endocrine Society, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(6)
Osteoporosis: percentage of female patients aged 65 years and older who have a central DXA measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 18 years and older with one of the following conditions or therapies: receiving oral glucocorticosteroid therapy for greater than 3 months OR hypogonadism OR fracture history OR transplant history OR obesity surgery OR malabsorption disease OR receiving aromatase therapy for breast cancer who had a central dual-energy X-ray absorptiometry (DXA) ordered or performed or pharmacologic therapy prescribed within 12 months.
Osteoporosis: percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient's on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.
Osteoporosis: percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.
Osteoporosis: percentage of patients aged 50 years and older with a fracture of the hip, spine or distal radius who had a central DXA measurement ordered or performed or pharmacologic therapy prescribed.
Osteoporosis: percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake, and exercise at least once within 12 months.
American Medical Association on behalf of the American Academy of Dermatology, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(4)
Melanoma: percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma who were entered into a recall system with the date for the next complete physical skin exam specified, at least once within the 12 month reporting period.
Melanoma: percentage of patients, regardless of age, with a new diagnosis of melanoma or a history of melanoma who received all of the following aspects of care within the 12 month reporting period: (1) patient was asked about new and changing moles AND (2) patient received a complete physical skin examination AND (3) patient was counseled to perform a monthly self skin examination.
Melanoma: percentage of patients, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.
Melanoma: percentage of patients, regardless of age, with stage 0 or IA melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered.
American Medical Association on behalf of the American Academy of Neurology, American College of Radiology, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(8)
Stroke and stroke rehabilitation: percentage of final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the hospital for patients aged 18 years and older with either a diagnosis of ischemic stroke or TIA or intracranial hemorrhage or at least one documented symptom consistent with ischemic stroke or TIA or intracranial hemorrhage that include documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke who did not receive intravenous unfractionated heparin.
Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for tissue plasminogen activator (t-PA) administration.
American Medical Association on behalf of the American Academy of Ophthalmology, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(10)
Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy AND the presence or absence of macular edema during one or more office visits within 12 months.
Eye care: percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes regarding the findings of the macular or fundus exam at least once within 12 months.
Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma or their caregiver who were counseled within 12 months about 1) the potential impact of glaucoma on their visual functioning and quality of life, and 2) the importance of treatment adherence.
Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma who have an optic nerve head evaluation during one or more office visits within 12 months.
Eye care: percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level a plan of care was documented within 12 months.
Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had
cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence.
Eye care: percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.
Eye care: percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL placement who received a comprehensive preoperative assessment of 1) dilated fundus exam; 2) axial length, corneal keratometry measurement, and method of IOL power calculation; and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL placement within 12 months prior to cataract surgery.
Eye care: percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the AREDS formation for preventing progression of AMD.
Eye care: percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage, AND the level of macular degeneration severity during one or more office visits within 12 months.
American Medical Association on behalf of the American Academy of Orthopaedic Surgeons and Physician Consortium for Performance Improvement®(7)
Osteoarthritis: percentage of patient visits during which an anti-inflammatory agent or analgesic was considered.
Osteoarthritis: percentage of patient visits during which gastrointestinal (GI) prophylaxis was considered.
Osteoarthritis: percentage of patient visits during which therapeutic exercise for the knee (therapeutic exercise instructed or physical therapy prescribed) was considered.
Osteoarthritis: percentage of patient visits with assessment for function and pain.
Osteoarthritis: percentage of patient visits with assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications.
Osteoarthritis: percentage of patients for whom a physical examination of the involved joint was performed during the initial visit.
Osteoarthritis: percentage of patients on prescribed or over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) who were assessed for gastrointestinal (GI)/renal risk factors.
American Medical Association on behalf of the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) Foundation and Physician Consortium for Performance Improvement®(8)
Acute otitis externa (AOE): percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with assessment for auricular or periauricular pain.
Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.
Acute otitis externa (AOE): percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations.
Otitis media with effusion (OME): percentage of patient visits for those patients aged 2 months through 12 years with a diagnosis of OME with assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry.
Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who received tympanostomy tube insertion who had a hearing test performed within 6 months prior to tympanostomy tube insertion.
Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.
Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids.
Otitis media with effusion (OME): percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed/recommended either antihistamines or decongestants.
American Medical Association on behalf of the American Academy of Pediatrics, American Academy of Family Physicians, and Physician Consortium for Performance Improvement®(4)
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis for whom an appropriate oral rehydration solution was recommended.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had documentation of hydration status.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had weight measurement recorded.
Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis whose parent/caregiver received education on diet and when to contact the physician.
American Medical Association on behalf of the American College of Cardiology, American Heart Association, and Physician Consortium for Performance Improvement®(26)
Atrial fibrillation (AF) and atrial flutter: percentage of calendar months during the reporting year during which patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter, receiving warfarin therapy, have at least one INR measurement made.
Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period.
Atrial fibrillation (AF) and atrial flutter: percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter with an assessment of all of the specified thromboembolic risk factors documented.
Chronic stable coronary artery disease (CAD): percentage of patients evaluated for both level of activity and anginal symptoms during one or more office visits.
Chronic stable coronary artery disease (CAD): percentage of patients identified as cigarette smokers who received a smoking cessation intervention.
Chronic stable coronary artery disease (CAD): percentage of patients queried one or more times about cigarette smoking.
Chronic stable coronary artery disease (CAD): percentage of patients who also have diabetes and/or left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.
Chronic stable coronary artery disease (CAD): percentage of patients who had a blood pressure measurement during the last office visit.
Chronic stable coronary artery disease (CAD): percentage of patients who received at least one lipid profile (or ALL component tests).
Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed antiplatelet therapy.
Chronic stable coronary artery disease (CAD): percentage of patients who were prescribed lipid lowering therapy.
Chronic stable coronary artery disease (CAD): percentage of patients who were screened for diabetes.
Chronic stable coronary artery disease (CAD): percentage of patients with prior myocardial infarction (MI) who were prescribed beta-blocker therapy.
Heart failure: percentage of patient visits with assessment of activity level for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with assessment of clinical signs of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with assessment of clinical symptoms of volume overload (excess) for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with blood pressure measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patient visits with weight measurement recorded for patients aged greater than or equal to 18 years with diagnosed heart failure (HF).
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy.
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have left ventricular systolic dysfunction (LVSD) who were prescribed beta-blocker therapy.
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure (HF) who also have paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy.
Heart failure: percentage of patients aged greater than or equal to 18 years with diagnosed heart failure who were provided with patient education on disease management and health behavior changes during one or more visit(s).
Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years for whom initial laboratory testing was performed.
Heart failure: percentage of patients with diagnosed heart failure (HF) aged greater than or equal to 18 years with quantitative or qualitative results of left ventricular function (LVF) assessment recorded.
Hypertension: percentage of patient visits during which either systolic blood pressure is greater than or equal to 140 mm Hg or diastolic blood pressure is greater than or equal to 90 mm Hg, with documented plan of care for hypertension.
Hypertension: percentage of patient visits with blood pressure measurement recorded.
American Medical Association on behalf of the American College of Emergency Physicians, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(9)
Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed.
Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with mental status assessed.
Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed.
Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed.
Emergency medicine: percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG performed.
Emergency medicine: percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed.
Emergency medicine: percentage of patients, regardless of age, with an emergency department diagnosis of acute myocardial infarction who received fibrinolytic therapy and the fibrinolytic therapy was ordered by the physician within 20 minutes of performing the 12-lead ECG.
Emergency medicine: percentage of patients, regardless of age, with an emergency department diagnosis of STEMI or new LBBB on 12-lead ECG who received primary PCI who had documentation that the emergency physician initiated communication with the cardiology intervention service within 10 minutes of the diagnostic 12-lead ECG.
Emergency medicine: percentage of patients, regardless of age, with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay.
American Medical Association on behalf of the American College of Radiology, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(8)
Radiology: percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.
Radiology: percentage of final reports for CT examinations performed with documentation of use of appropriate radiation dose reduction devices OR manual techniques for appropriate moderation of exposure.
Radiology: percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time.
Radiology: percentage of final reports for screening mammograms that are classified "probably benign."
Radiology: percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.
Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the patient within 5 business days of exam interpretation.
Radiology: percentage of patients undergoing diagnostic mammograms that are classified as "suspicious" or "highly suggestive of malignancy" with documentation of direct communication of findings from the diagnostic mammogram to the practice that manages the patient's on-going care within 3 business days of exam interpretation.
Radiology: percentage of patients undergoing screening mammograms whose assessment category (e.g., Mammography Quality Standards Act [MQSA], Breast Imaging Reporting and Data System [BI-RADS®], or FDA approved equivalent categories) is entered into an internal database that will, at a minimum, allow analysis of abnormal interpretation (recall) rate.
American Medical Association on behalf of the American College of Surgeons, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(6)
Perioperative care: percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics and who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time.
Perioperative care: percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics and who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 24 hours of surgical end time.
Perioperative care: percentage of patients undergoing procedures for which VTE prophylaxis is indicated in all patients who had an order for low-molecular weight heparin (LMWH), low-dose unfractionated heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time.
Perioperative care: percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first or second generation cephalosporin prophylactic antibiotic who had an order for cefazolin or cefuroxime for antimicrobial prophylaxis.
Perioperative care: percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics who have an order for an antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).
Perioperative care: percentage of surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of a prophylactic antibiotic has been initiated within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).
American Medical Association on behalf of the American Gastroenterological Association Institute and Physician Consortium for Performance Improvement®(15)
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD who did not have a barium swallow test ordered.
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed.
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with a diagnosis of GERD or heartburn whose endoscopy report indicates a suspicion of Barrett's esophagus who had a forceps esophageal biopsy performed.
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding.
Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with the diagnosis of GERD who have been prescribed chronic proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) therapy who received an assessment of their GERD symptoms within 12 months.
Hepatitis C: percentage of female patients aged 18 to 44 years and all men aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were counseled regarding contraception prior to the initiation of antiviral treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of antiviral treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at 12 weeks from initiation of antiviral treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were prescribed peginterferon and ribavirin therapy within the 12 month reporting period.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C with genotype 1 or 4 who are receiving antiviral treatment at week 24 for whom quantitative HCV RNA testing was performed at 24 weeks of treatment.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial evaluation who had HCV RNA testing ordered or previously performed.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B.
Hepatitis C: percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were counseled regarding the risks of alcohol consumption at least once within the 12 month reporting period.
American Medical Association on behalf of the American Geriatrics Society, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(9)
Geriatrics: percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence who were prescribed a medication to treat the urinary incontinence who had a trial of behavioral therapy documented.
Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months.
Geriatrics: percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.
Geriatrics: percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.
Geriatrics: percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
Geriatrics: percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months.
Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.
Geriatrics: percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months.
American Medical Association on behalf of the American Psychiatric Association, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(3)
Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.
Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period.
Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period.
American Medical Association on behalf of the American Society for Therapeutic Radiology and Oncology, American Society of Clinical Oncology, and Physician Consortium for Performance Improvement®(10)
Oncology: percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12 month reporting period.
Oncology: percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy or have previously received adjuvant chemotherapy within the 12 month reporting period.
Oncology: percentage of patients with a diagnosis of cancer receiving chemotherapy or radiation therapy with a pathology report in the medical record that confirms malignancy prior to the initiation of therapy.
Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which includes, at a minimum: drug[s] prescribed, dose, and duration) is documented prior to the initiation of the new treatment regimen.
Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period.
Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have completed chemotherapy within the 12 month reporting period who: A) have a chemotherapy treatment summary documented in the chart; AND B) have documentation that the written chemotherapy treatment summary was provided to the patient; AND C) have documentation that the chemotherapy treatment summary was communicated to the physician(s) providing continuing care.
Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to physician(s) providing continuing care and to the patient within one month completing treatment.
Oncology: percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer who receive 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues.
Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.
Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.
American Medical Association on behalf of the American Society of Anesthesiologists and Physician Consortium for Performance Improvement®(3)
Anesthesiology and critical care: percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who had an order on the first ventilator day for head of bed elevation (30-45 degrees).
Anesthesiology and critical care: percentage of patients who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique followed.
Anesthesiology and critical care: percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.
American Medical Association on behalf of the American Society of Gastrointestinal Endoscopy, American Gastroenterological Association, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(3)
Endoscopy and polyp surveillance: percentage of final colonoscopy reports for patients aged 18 years and older that include documentation of all of the following: pre-procedure risk assessment; depth of insertion; quality of the bowel prep; complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; and recommendations for follow-up.
Endoscopy and polyp surveillance: percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp in previous colonoscopy findings who had a follow-up interval of 3 or more years since their last colonoscopy documented in the colonoscopy report.
Endoscopy and polyp surveillance: percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.
American Medical Association on behalf of the American Society of Hematology and Physician Consortium for Performance Improvement®(4)
Hematology: percentage of patients aged 18 years and older with a diagnosis of chronic lymphocytic leukemia (CLL) who had baseline flow cytometry studies performed.
Hematology: percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period.
Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.
Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin therapy.
American Medical Association on behalf of the American Society of Pediatric Nephrology and Physician Consortium for Performance Improvement(2)
Pediatric end stage renal disease (ESRD): percentage of calendar months during the 12 month reporting period in which patients aged 17 years and younger with a diagnosis of ESRD receiving hemodialysis have a single-pool Kt/V greater than or equal to 1.2 or have a single-pool Kt/V less than 1.2 with a documented plan of care for inadequate hemodialysis.
Pediatric end stage renal disease (ESRD): percentage of patients aged 6 months through 17 years with a diagnosis of ESRD and receiving dialysis seen for a visit between November 1 and February 15 of the one-year measurement period who have documented administration of influenza immunization OR patient reported receipt of an influenza immunization from another provider.
American Medical Association on behalf of the American Society of Plastic Surgeons, Physician Consortium for Performance Improvement®, and National Committee for Quality Assurance(7)
Chronic wound care: percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without a prescription or recommendation to use wet to dry dressings.
Chronic wound care: percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of chronic skin ulcer undergoing debridement with documentation of wound characteristics (including at a minimum: size, AND nature of wound base tissue, AND amount of drainage) prior to debridement.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of diabetes and foot ulcer who received education regarding appropriate foot care AND daily inspection of the feet within the 12 month reporting period.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of diabetes and foot ulcer who were prescribed an appropriate method of offloading (pressure relief) within the 12 month reporting period.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of venous ulcer who received education regarding the need for long term compression therapy including interval replacement of compression stockings within the 12 month reporting period.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of venous ulcer who were prescribed compression therapy within the 12 month reporting period.
American Medical Association on behalf of the American Urological Association and Physician Consortium for Performance Improvement®(6)
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving external beam radiotherapy as primary therapy to the prostate with or without nodal irradiation (no metastases; no salvage therapy) who receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT).
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who received counseling on, at a minimum, the following treatment options for clinically localized disease prior to initiation of treatment: active surveillance, AND interstitial prostate brachytherapy, AND external beam radiotherapy, AND radical prostatectomy.
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence, receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist).
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score prior to initiation of treatment.
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer, at low risk of recurrence, receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.
Prostate cancer: percentage of patients, regardless of age, with a new diagnosis of prostate cancer with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score.
American Medical Association on behalf of the College of American Pathologists and Physician Consortium for Performance Improvement®(2)
Pathology: percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.
Pathology: percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.
American Medical Association on behalf of the Physician Consortium for Performance Improvement®(49)
Asthma: percentage of patients aged 5 to 40 years diagnosed with mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment.
Asthma: percentage of patients aged 5 to 40 years with diagnosed asthma who were evaluated during at least one office visit during the reporting year for the frequency (numeric) of daytime and nocturnal asthma symptoms.
Child and adolescent major depressive disorder: percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with a plan for follow-up care documented.
Child and adolescent major depressive disorder: percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.
Child and adolescent major depressive disorder: percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder for whom an antidepressant medication was considered or prescribed during an episode of major depressive disorder.
Child and adolescent major depressive disorder: percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder who received or were referred for psychotherapy during an episode of major depressive disorder.
Child and adolescent major depressive disorder: percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder who were interviewed directly by the evaluating clinician on or before the date of diagnosis.
Child and adolescent major depressive disorder: percentage of patients aged 6 through 17 years with a diagnosis of major depressive disorder with documented evidence that they met the DSM-IV criteria [at least 5 elements with symptom duration of two weeks or longer, including 1) depressed mood (can be irritable mood in children and adolescents) or 2) loss of interest or pleasure] during the visit in which the new diagnosis or recurrent episode was identified.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older who had a spirometry evaluation results documented at least annually.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and an oxygen saturation less than or equal to 88% or a PaO2 less than or equal to 55 mm Hg who prescribed long term oxygen therapy.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and dyspnea for whom exercise training was recommended.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and FEV1 less than 40% of predicted value who have oxygen saturation assessed at least annually.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD identified as smokers who received a smoking cessation intervention at least annually.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who received a pneumococcus immunization.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who received influenza immunization during current flu season.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were assessed for COPD symptoms at least annually.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were assessed for pneumococcus immunization status.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were queried about smoking at least annually.
Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were recommended to receive an influenza immunization annually.
Community-acquired bacterial pneumonia: percentage of patients who had a documented rationale for level of care based on severity and safety of home care.
Community-acquired bacterial pneumonia: percentage of patients who received a smoking cessation intervention.
Community-acquired bacterial pneumonia: percentage of patients who were assessed for co-morbid conditions.
Community-acquired bacterial pneumonia: percentage of patients who were assessed for influenza immunization status.
Community-acquired bacterial pneumonia: percentage of patients who were assessed for pneumococcus immunization status.
Community-acquired bacterial pneumonia: percentage of patients who were prescribed an appropriate empiric antibiotic.
Community-acquired bacterial pneumonia: percentage of patients who were queried about smoking.
Community-acquired bacterial pneumonia: percentage of patients with a chest x-ray performed.
Community-acquired bacterial pneumonia: percentage of patients with hydration status assessed.
Community-acquired bacterial pneumonia: percentage of patients with mental status assessed.
Community-acquired bacterial pneumonia: percentage of patients with oxygen saturation assessed.
Community-acquired bacterial pneumonia: percentage of patients with vital signs recorded.
Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who had a suicide risk assessment completed at each visit during the measurement period.
Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who receive therapy appropriate to their classification during the measurement period.
Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who were initially treated with antidepressant medication who had the antidepressant medication discontinued who were continued on antidepressant medication for a minimum of 16 weeks following remission of symptoms during the measurement period.
Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD whose severity of depressive disorder was assessed during the visit in which the new diagnosis or recurrent episode was identified during the measurement period.
Major depressive disorder (MDD): percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD, who met the DSM-IV criteria during the visit in which the new diagnosis or recurrent episode was identified.
Prenatal care: percentage of D (Rh) negative, unsensitized patients, regardless of age, who gave birth during a 12-month period who received anti-D immune globulin at 26-30 weeks gestation.
Prenatal care: percentage of patients, regardless of age, who gave birth during a 12-month period who were screened for HIV infection during the first or second prenatal care visit.
Preventive care and screening: percentage of female patients aged 21 through 65 years who have documentation of the performance of current cervical cancer screening with results during the two-year measurement period.
Preventive care and screening: percentage of female patients who had a mammogram performed during the two-year measurement period. [NQMC Update Pending]
Preventive care and screening: percentage of patients 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user.
Preventive care and screening: percentage of patients aged 18 years and older for whom body mass index (BMI) is documented at least once during the two-year measurement period.
Preventive care and screening: percentage of patients aged 18 years and older who were screened for unhealthy alcohol use at least once during the two-year measurement period using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user.
Preventive care and screening: percentage of patients aged 18 years and older who were screened for unhealthy alcohol use at least once during the two-year measurement period using a systematic screening method.
Preventive care and screening: percentage of patients aged 65 years and older who have documentation of receiving pneumococcal immunization during the two-year measurement period.
Preventive care and screening: percentage of patients screened for colorectal cancer during the one-year measurement period. [NQMC Update Pending]
Preventive care and screening: percentage of patients who received an influenza immunization during the one-year measurement period. [NQMC Update Pending]
Preventive care and screening: percentage of patients who were queried about tobacco use one or more times during the two-year measurement period. [NQMC Update Pending]
American Medical Association on behalf of the Physician Consortium for Performance Improvement® and Society of Nuclear Medicine(2)
Nuclear medicine - radionuclide bone imaging: percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT) that were performed.
Nuclear medicine - radionuclide bone imaging: percentage of patients, regardless of age, undergoing bone scintigraphy, considered to be potentially at risk for fracture in a weight-bearing site for whom there is documentation of direct communication to the referring physician within 24 hours of completion of the imaging study.
American Medical Association on behalf of the Renal Physicians Association and Physician Consortium for Performance Improvement®(12)
Chronic kidney disease (CKD): percentage of calendar months during the 12 months reporting period in which patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), receiving ESA therapy, have a hemoglobin less than 13 g/dL OR patients whose hemoglobin is greater than or equal to 13 g/dL have a documented plan of care.
Chronic kidney disease (CKD): percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), and hypertension and proteinuria who were prescribed ACE inhibitor or ARB therapy during the 12 months reporting period.
Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who had the following laboratory testing ordered at least once during the 12 month reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile.
Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who received the influenza immunization during the flu season (September through February).
Chronic kidney disease (CKD): percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), who were referred for AV fistula at least once during the 12 month reporting period.
Chronic kidney disease (CKD): percentage of visits for patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not receiving RRT), with a blood pressure less than 130/80 mmHg OR blood pressure greater than or equal to 130/80 mmHg with a documented plan of care.
End stage renal disease (ESRD): percentage of patient calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD receiving hemodialysis have a Kt/V greater than or equal to 1.2 OR patients have a Kt/V less than 1.2 with a documented plan of care for inadequate hemodialysis.
End stage renal disease (ESRD): percentage of patient calendar months during the 12 month reporting period in which patients aged 18 years and older with a diagnosis of ESRD who are receiving dialysis have a Hgb greater than or equal to 11g/dL OR have a Hgb less than 11g/dL with a documented plan of care for anemia.
End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis who received the influenza vaccination during the flu season (September through February).
End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis who have a functioning AV fistula OR patients who are referred for an AV fistula at least once during the 12 month reporting period.
End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving hemodialysis with a permanent catheter who are referred for evaluation for AV fistula at least once during the 12 month reporting period.
End stage renal disease (ESRD): percentage of patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal dialysis who have a Kt/V greater than or equal to 1.7 OR patients who have a Kt/V less than 1.7 with a documented plan of care for inadequate peritoneal dialysis at least three times (every 4 months) during the 12 month reporting period.
American Medical Directors Association(65)
Heart failure: average time for a patient's ineffective treatment to be modified.
Heart failure: average time taken to respond to a patient's adverse drug reaction.
Heart failure: percentage of patients monitored for adverse drug reactions.
Heart failure: percentage of patients referred to cardiology/hospice/palliative care (after several ineffective modifications and based on patient's advance directive).
Heart failure: percentage of patients where heart failure is diagnosed urgently or emergently (i.e., not on admission or at periodic assessment).
Heart failure: percentage of patients with documentation that appropriate lab monitoring has been ordered.
Heart failure: percentage of patients with documented assessment for heart failure risk factors.
Heart failure: percentage of patients with documented assessment for imaging studies.
Heart failure: percentage of patients with documented assessment for reversible causes of heart failure.
Heart failure: percentage of patients with documented assessment for reversible etiology workup.
Heart failure: percentage of patients with documented assessment for signs, symptoms, and heart failure risk factors at admission.
Heart failure: percentage of patients with documented consideration of angiotensin-converting enzyme (ACE) inhibitor treatment.
Heart failure: percentage of patients with documented consideration of beta-blocker treatment.
Heart failure: percentage of patients with documented discussions regarding advance directives and/or adherence to the directive.
Heart failure: percentage of patients with documented periodic assessment for peripheral edema and other heart failure risk factors.
Heart failure: percentage of patients with documented periodic monitoring of heart failure symptoms (lung sounds, edema, decreased activity).
Heart failure: percentage of patients with heart failure on angiotensin-converting enzyme (ACE) inhibitor.
Heart failure: percentage of patients with heart failure on beta-blocker.
Heart failure: percentage of patients with heart failure on diuretic therapy for at least 6 months with electrolyte measures within normal ranges.
Heart failure: percentage of patients with heart failure on diuretic therapy who had electrolyte monitoring within the past 2 months.
Heart failure: percentage of patients with heart failure prescribed a low-sodium diet in the past 6 months.
Heart failure: percentage of patients with heart failure prescribed pharmacologic agents consistent with patient's advance care directive.
Heart failure: percentage of patients with heart failure prescribed pharmacologic agents consistent with severity of heart failure.
Heart failure: percentage of patients with heart failure prescribed pharmacologic agents consistent with type of ventricular dysfunction.
Heart failure: percentage of patients with heart failure readmitted for acute episode of heart failure.
Heart failure: percentage of patients with heart failure receiving nonpharmacologic treatment, such as diet intervention and fluid restriction.
Heart failure: percentage of patients with heart failure sent to emergency room (ER) for acute exacerbation.
Heart failure: percentage of patients with heart failure weighed as per physician's orders.
Heart failure: percentage of patients with heart failure weighed daily.
Heart failure: percentage of patients with heart failure with documented assessment of treatment effectiveness.
Heart failure: percentage of patients with heart failure with fluid volume overload prescribed a loop diuretic.
Heart failure: percentage of patients with medical record documentation for characterization of ventricular dysfunction as systolic or diastolic.
Heart failure: percentage of patients with medical record documentation indicating communication of signs and symptoms of heart failure by direct care team to physician/nurse practitioner/physician assistant.
Pain management in the long-term care setting: percentage of patients prescribed narcotics for pain with appropriate bowel management program in place.
Pain management in the long-term care setting: percentage of patients receiving physical complementary treatments.
Pain management in the long-term care setting: percentage of patients receiving physical exam to assess for causes of pain.
Pain management in the long-term care setting: percentage of patients with adverse drug reactions (ADRs) to pain medications.
Pain management in the long-term care setting: percentage of patients with appropriate treatment for pain.
Pain management in the long-term care setting: percentage of patients with cognitive and language problems receiving targeted pain assessment.
Pain management in the long-term care setting: percentage of patients with controlled adverse drug reactions (ADRs) to pain medications.
Pain management in the long-term care setting: percentage of patients with documented absence of pain symptoms after treatment.
Pain management in the long-term care setting: percentage of patients with documented assessment for pain using standardized tool at each quarterly review.
Pain management in the long-term care setting: percentage of patients with documented assessment for pain using standardized tool at each reported change of condition requiring minimum data set (MDS) notation.
Pain management in the long-term care setting: percentage of patients with documented assessment for pain using standardized tool on admission.
Pain management in the long-term care setting: percentage of patients with documented care plan for acute or chronic pain.
Pain management in the long-term care setting: percentage of patients with documented cause of pain symptoms.
Pain management in the long-term care setting: percentage of patients with documented complete assessment of pain covering all pertinent components of pain.
Pain management in the long-term care setting: percentage of patients with documented medication regimen with evidence of titration/adjustment in accordance with World Health Organization (WHO) step ladder.
Pain management in the long-term care setting: percentage of patients with documented reasons for no medical work-up.
Pain management in the long-term care setting: percentage of patients with documented reduction of pain symptoms.
Pain management in the long-term care setting: percentage of patients with orders for not recommended drugs.
Pain management in the long-term care setting: percentage of patients with periodic documented assessment by nursing staff of effectiveness of pain management.
Pain management in the long-term care setting: percentage of patients with periodic documented assessment of effectiveness of pain management by medical doctor (MD).
Pressure ulcers: percentage of patients in facility admitted with a pressure ulcer.
Pressure ulcers: percentage of patients in facility who develop pressure ulcers while in the facility.
Pressure ulcers: percentage of patients with a pressure ulcer or pressure ulcer risk with documented periodic assessment for specific risk factors.
Pressure ulcers: percentage of patients with clinically significant complications.
Pressure ulcers: percentage of patients with documented assessment of pressure ulcer using a formal wound staging classification.
Pressure ulcers: percentage of patients with documented assessment of risks for possible pressure ulcer development.
Pressure ulcers: percentage of patients with documented assessment of skin for breakdown.
Pressure ulcers: percentage of patients with pressure ulcers that heal.
Pressure ulcers: percentage of patients with pressure ulcers with documented treatment plan for pressure reduction approaches.
Pressure ulcers: percentage of patients with pressure ulcers with documented treatment plans citing identified risk factors and co-morbid conditions.
Pressure ulcers: percentage of patients with pressure ulcers with necrotic tissue or slough with documented treatment plan for wound debridement.
Pressure ulcers: percentage of patients with pressure ulcers with periodic documentation on status of the characteristics of wound (e.g., size, depth, color, induration, odor, discharge).
American Physical Therapy Association(1)
Physical functional status: mean change score in patients' mobility following physical therapy intervention as assessed using the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) Instrument.
American Podiatric Medical Association(2)
Diabetes mellitus: percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a lower extremity neurological exam performed at least once within 12 months.
Diabetes mellitus: percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing during one or more office visits within 12 months.
American Psychiatric Association(3)
Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.
Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current opioid addiction who were counseled regarding psychosocial AND pharmacologic treatment options for opioid addiction within the 12 month reporting period.
Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period.
American Society for Therapeutic Radiology and Oncology(10)
Oncology: percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12 month reporting period.
Oncology: percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy or have previously received adjuvant chemotherapy within the 12 month reporting period.
Oncology: percentage of patients with a diagnosis of cancer receiving chemotherapy or radiation therapy with a pathology report in the medical record that confirms malignancy prior to the initiation of therapy.
Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which includes, at a minimum: drug[s] prescribed, dose, and duration) is documented prior to the initiation of the new treatment regimen.
Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period.
Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have completed chemotherapy within the 12 month reporting period who: A) have a chemotherapy treatment summary documented in the chart; AND B) have documentation that the written chemotherapy treatment summary was provided to the patient; AND C) have documentation that the chemotherapy treatment summary was communicated to the physician(s) providing continuing care.
Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to physician(s) providing continuing care and to the patient within one month completing treatment.
Oncology: percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer who receive 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues.
Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.
Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.
American Society of Anesthesiologists(3)
Anesthesiology and critical care: percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who had an order on the first ventilator day for head of bed elevation (30-45 degrees).
Anesthesiology and critical care: percentage of patients who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique followed.
Anesthesiology and critical care: percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.
American Society of Clinical Oncology(17)
Breast cancer: percentage of patients for whom combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c, or stage II or III hormone receptor negative breast cancer.
Breast cancer: percentage of patients for whom radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.
Breast cancer: percentage of patients for whom tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage II or III hormone receptor positive breast cancer.
Colon cancer: percentage of patients for whom adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC stage III (lymph node positive) colon cancer.
Colon cancer: percentage of patients for whom at least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.
Oncology: percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12 month reporting period.
Oncology: percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy or have previously received adjuvant chemotherapy within the 12 month reporting period.
Oncology: percentage of patients with a diagnosis of cancer receiving chemotherapy or radiation therapy with a pathology report in the medical record that confirms malignancy prior to the initiation of therapy.
Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which includes, at a minimum: drug[s] prescribed, dose, and duration) is documented prior to the initiation of the new treatment regimen.
Oncology: percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once during the 12 month reporting period.
Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have completed chemotherapy within the 12 month reporting period who: A) have a chemotherapy treatment summary documented in the chart; AND B) have documentation that the written chemotherapy treatment summary was provided to the patient; AND C) have documentation that the chemotherapy treatment summary was communicated to the physician(s) providing continuing care.
Oncology: percentage of patients, regardless of age, with a diagnosis of cancer who have undergone brachytherapy or external beam radiation therapy who have a treatment summary report in the chart that was communicated to physician(s) providing continuing care and to the patient within one month completing treatment.
Oncology: percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer who receive 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues.
Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.
Oncology: percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.
Rectal cancer: percentage of patients for whom postoperative adjuvant chemotherapy is considered or administered within 9 months (270 days) of diagnosis for patients under the age 80 years with AJCC stage II or stage III rectal cancer.
Rectal cancer: percentage of patients for whom radiation therapy is considered or administered within 6 months (180 days) of diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or stage III receiving surgical resection for rectal cancer.
American Society of Clinical Oncology/National Comprehensive Cancer Network(7)
Breast cancer: percentage of patients for whom combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c, or stage II or III hormone receptor negative breast cancer.
Breast cancer: percentage of patients for whom radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.
Breast cancer: percentage of patients for whom tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage II or III hormone receptor positive breast cancer.
Colon cancer: percentage of patients for whom adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC stage III (lymph node positive) colon cancer.
Colon cancer: percentage of patients for whom at least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.
Rectal cancer: percentage of patients for whom postoperative adjuvant chemotherapy is considered or administered within 9 months (270 days) of diagnosis for patients under the age 80 years with AJCC stage II or stage III rectal cancer.
Rectal cancer: percentage of patients for whom radiation therapy is considered or administered within 6 months (180 days) of diagnosis for patients under the age of 80 with clinical or pathologic AJCC T4N0M0 or stage III receiving surgical resection for rectal cancer.
American Society of Gastrointestinal Endoscopy(3)
Endoscopy and polyp surveillance: percentage of final colonoscopy reports for patients aged 18 years and older that include documentation of all of the following: pre-procedure risk assessment; depth of insertion; quality of the bowel prep; complete description of polyp(s) found, including location of each polyp, size, number and gross morphology; and recommendations for follow-up.
Endoscopy and polyp surveillance: percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp in previous colonoscopy findings who had a follow-up interval of 3 or more years since their last colonoscopy documented in the colonoscopy report.
Endoscopy and polyp surveillance: percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.
American Society of Hematology(4)
Hematology: percentage of patients aged 18 years and older with a diagnosis of chronic lymphocytic leukemia (CLL) who had baseline flow cytometry studies performed.
Hematology: percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period.
Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.
Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin therapy.
American Society of Pediatric Nephrology(2)
Pediatric end stage renal disease (ESRD): percentage of calendar months during the 12 month reporting period in which patients aged 17 years and younger with a diagnosis of ESRD receiving hemodialysis have a single-pool Kt/V greater than or equal to 1.2 or have a single-pool Kt/V less than 1.2 with a documented plan of care for inadequate hemodialysis.
Pediatric end stage renal disease (ESRD): percentage of patients aged 6 months through 17 years with a diagnosis of ESRD and receiving dialysis seen for a visit between November 1 and February 15 of the one-year measurement period who have documented administration of influenza immunization OR patient reported receipt of an influenza immunization from another provider.
American Society of Plastic Surgeons(7)
Chronic wound care: percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without a prescription or recommendation to use wet to dry dressings.
Chronic wound care: percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of chronic skin ulcer undergoing debridement with documentation of wound characteristics (including at a minimum: size, AND nature of wound base tissue, AND amount of drainage) prior to debridement.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of diabetes and foot ulcer who received education regarding appropriate foot care AND daily inspection of the feet within the 12 month reporting period.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of diabetes and foot ulcer who were prescribed an appropriate method of offloading (pressure relief) within the 12 month reporting period.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of venous ulcer who received education regarding the need for long term compression therapy including interval replacement of compression stockings within the 12 month reporting period.
Chronic wound care: percentage of patients aged 18 years and older with a diagnosis of venous ulcer who were prescribed compression therapy within the 12 month reporting period.
American Speech-Language-Hearing Association(15)
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Alaryngeal Communication Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Attention Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Augmentative-Alternative Communication Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Fluency Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Memory Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Motor Speech Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Pragmatics Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Problem Solving Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Reading Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Spoken Language Comprehension Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Spoken Language Expression Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Swallowing Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Voice Following Tracheostomy Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Voice Functional Communication Measure (FCM).
Speech and language function: proportion of stroke patients in each risk-adjusted group that make at least one level of progress on the Writing Functional Communication Measure (FCM).
American Urological Association(6)
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving external beam radiotherapy as primary therapy to the prostate with or without nodal irradiation (no metastases; no salvage therapy) who receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT).
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who received counseling on, at a minimum, the following treatment options for clinically localized disease prior to initiation of treatment: active surveillance, AND interstitial prostate brachytherapy, AND external beam radiotherapy, AND radical prostatectomy.
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence, receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist).
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score prior to initiation of treatment.
Prostate cancer: percentage of patients, regardless of age, with a diagnosis of prostate cancer, at low risk of recurrence, receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.
Prostate cancer: percentage of patients, regardless of age, with a new diagnosis of prostate cancer with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason score.
Anderson, Roger T., Ph.D., Medical Quality Enhancement Corporation(2)
Patients' satisfaction with care: patients' overall rating of their physician's office.
Patients' satisfaction with care: patients' overall rating of their physician.
Arthritis Foundation(51)
Acetaminophen use: percentage of patients prescribed acetaminophen who have risk factors for liver disease AND the percentage of patients treated with high-dose (greater than or equal to 4 gm/day) acetaminophen who are advised of the associated risk of liver toxicity.
Cyclooxygenase 2 (COX-2)-selective non-steroidal anti-inflammatory drug (NSAID) use: percentage of patients treated with a COX-2-selective NSAID who are taking low-dose aspirin daily and have risk factors for GI bleeding who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).
Low-dose aspirin use: percentage of patients treated with a low-dose aspirin daily who have 2 or more risk factors for GI bleeding who are treated concomitantly with either misoprostol or proton pump inhibitor (PPI).
Low-dose aspirin: percentage of patients prescribed low-dose aspirin (less than or equal to 325 mg/day) who are advised of the associated GI bleeding risks.
Non-selective non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with a non-selective NSAID who have risk factors for GI bleeding and who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).
Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who are NOT treated with a low-dose aspirin, have risk factors for GI bleeding and are prescribed an NSAID who receive either a non-selective NSAID plus a gastroprotective agent (proton pump inhibitor [PPI] or misoprostol) or a COX-2-selective NSAID.
Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who take coumadin and are prescribed an NSAID who receive either a cyclooxygenase 2 (COX-2)-selective NSAID or a nonacetylated salicylate.
Non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients prescribed an NSAID (non selective or selective) who are advised of the associated GI bleeding and renal risks with the GI risks documented.
Osteoarthritis: percentage of overweight patients (as defined by body mass index of greater than or equal to 27 kg/m2) who are advised to lose weight annually to prevent incident knee or hip osteoarthritis.
Osteoarthritis: percentage of patients beginning drug treatment for "joint pain," "arthritis," or "arthralgia" for whom there is documentation that the affected joint was examined.
Osteoarthritis: percentage of patients with a diagnosis of osteoarthritis and reporting difficulties with non-ambulatory activities of daily living whose functional ability with problem tasks are assessed for need of non-ambulatory assistive devices to aid with problem tasks.
Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip and reporting difficulty walking to accomplish activities of daily living for greater than 3 months whose walking ability is assessed for need of ambulatory assistive devices.
Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip for greater than 3 months who are prescribed an exercise program.
Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip for greater than 3 months who receive or who are recommended patient education.
Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip with an initial and annual functional assessment.
Osteoarthritis: percentage of patients with a diagnosis of symptomatic osteoarthritis of the knee or hip with an initial and annual pain assessment.
Osteoarthritis: percentage of patients with hip or knee osteoarthritis and worsening complaints accompanied by a progressive decrease in activities and no previous radiographs during the preceding 3 months for whom a knee or hip radiograph is performed within 3 months.
Osteoarthritis: percentage of patients with osteoarthritis for whom oral pharmacologic therapy is changed from acetaminophen to a different oral agent with evidence that they have had a trial of maximum-dose acetaminophen (suitable for age and comorbidities).
Osteoarthritis: percentage of patients with osteoarthritis pain of mild or moderate severity for whom acetaminophen is the first drug used for initial nonnarcotic pharmacologic therapy to aid with problem tasks.
Osteoarthritis: percentage of patients with severe symptomatic osteoarthritis of the knee or hip who have failed to respond to nonpharmacologic and pharmacologic therapy who are referred to an orthopedic surgeon.
Osteoarthritis: percentage of patients with symptomatic osteoarthritis of the knee or hip and who are overweight (as defined by body mass index of greater than or equal to 27 kg/m2) and who are advised to lose weight to reduce symptoms of osteoarthritis.
Osteoarthritis: percentage of patients with symptomatic osteoarthritis of the knee or hip and who have been overweight (as defined by body mass index of greater than or equal to 27 kg/m2) for more than 3 years who are referred to a weight loss program.
Rheumatoid arthritis: percentage of female patients of childbearing age who are newly started on any of the following disease-modifying antirheumatic drugs (DMARDs): methotrexate, cyclophosphamide, azathioprine, sulfasalazine, chlorambucil, D-penicillamine, hydroxychloroquine, gold, etanercept, infliximab, leflunomide for whom a discussion with the patient about the teratogenic risks of these drugs and about contraception is documented.
Rheumatoid arthritis: percentage of patients being treated with methotrexate (MTX) who have elevations in serum transaminase levels above two times the upper range of normal for the laboratory two or more times over a three month period for whom non-steroidal anti-inflammatory drug (NSAID) or MTX dose reduction or discontinuation is documented within one month of the second abnormal laboratory result.
Rheumatoid arthritis: percentage of patients being treated with methotrexate for whom folate supplementation is given.
Rheumatoid arthritis: percentage of patients in the third trimester of pregnancy for whom non-steroidal anti-inflammatory drugs (NSAIDs) (selective and non-selective) and aspirin are not used.
Rheumatoid arthritis: percentage of patients newly prescribed acetaminophen for whom the risk versus benefits of this drug are discussed.
Rheumatoid arthritis: percentage of patients newly prescribed any of the following drugs: non-steroidal anti-inflammatory drugs (NSAIDs) (selective or non-selective), disease-modifying antirheumatic drugs (DMARDs), glucocorticoids, or narcotics for whom a discussion with the patient about the risks versus benefits of the chosen therapy is documented.
Rheumatoid arthritis: percentage of patients on immunosuppressive therapy for whom there is evidence that the following vaccines have been given: influenza (annually), pneumococcal, meningococcal, haemophilus B, hepatitis B, and tetanus.
Rheumatoid arthritis: percentage of patients receiving greater than or equal to 10 mg per day of prednisone (or equivalent) for greater than six months with no documentation of worsening disease for whom there is documentation at some point during the treatment course that a steroid taper was attempted or a disease-modifying antirheumatic drug (DMARD) dose was increased.
Rheumatoid arthritis: percentage of patients receiving immunosuppressants and/or steroid therapy (greater than 10 mg per day prednisone equivalent for greater than two weeks) for whom live/oral polio, live typhoid, yellow fever, measles, mumps, rubella (MMR), bacille Calmette-Guerin (BCG) vaccine are not used.
Rheumatoid arthritis: percentage of patients referred to a physician for a new diagnosis of rheumatoid arthritis who are seen by the physician within 3 months.
Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis (RA) for whom baseline x-rays of the hands or feet are performed within 3 months of the initial diagnosis and every 3 years.
Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis for whom each of the following are documented within 3 months of diagnosis and at appropriate time intervals thereafter: a joint examination of three or more joint areas, functional status, disease activity (presence/absence of synovitis), acute phase reactant (defined by erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP]) and pain (by visual analog scale [VAS] or other mechanism).
Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulties performing tasks involving use of their hands and wrists either because of stiffness or pain for whom functional ability with their hands and wrists is assessed for need of hand or wrist splints (orthoses).
Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulties with activities of daily living either because of stiffness or pain for whom functional ability with the compliant tasks is assessed for need of assistive devices to aid with compliant tasks.
Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulty with walking either because of stiffness, pain or instability for whom walking ability is assessed for need for ambulatory assistive devices including a cane, insoles, and orthotics.
Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis, no contraindications to exercise and who are physically and mentally able to exercise for whom a directed or supervised muscle strengthening or aerobic exercise program has been prescribed at least once and reviewed at least once per year.
Rheumatoid arthritis: percentage of patients with an established diagnosis of rheumatoid arthritis (RA) whose RA is evaluated by a physician at least annually.
Rheumatoid arthritis: percentage of patients with an established diagnosis of sero-positive rheumatoid arthritis (RA), or RA and synovitis or RA and radiographic erosions who are treated with a disease-modifying antirheumatic drug (DMARD) unless contraindication to DMARD is documented.
Rheumatoid arthritis: percentage of patients with established treatment with a disease-modifying antirheumatic drug (DMARD) or glucocorticoids for whom monitoring for drug toxicity is performed.
Rheumatoid arthritis: percentage of patients with rheumatoid arthritis and osteoporosis treated with oral or parenteral steroids for whom antiresorptive therapy is prescribed.
Rheumatoid arthritis: percentage of patients with rheumatoid arthritis started on prednisone greater than or equal to 10 mgs daily, (or other steroid equivalent) and who continue on prednisone for more than three months for whom 1,500 mg calcium and 400 international units (IUs) per day of Vitamin D are prescribed and antiresorptive therapy is discussed with the patient.
Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who are being treated with a disease-modifying antirheumatic drug (DMARD) and report worsening of symptoms over a six-month period of time and have evidence of active disease (synovitis) for whom one of the following are done: dose or route of DMARD administration is changed, DMARD is changed, an additional DMARD is added, or dose of glucocorticoids is started or increased.
Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who are newly prescribed a disease-modifying antirheumatic drug (DMARD) for whom appropriate baseline studies are documented within an appropriate period of time from the original prescription.
Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have joint pain, joint instability, or tendon rupture affecting the upper extremity or the foot or ankle, which significantly limits activities despite non-pharmacologic and pharmacologic interventions for whom referral to a surgeon is offered unless contraindication to surgery is documented.
Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have severe pain of the hips or knees, which significantly limits activities despite non-pharmacologic and pharmacologic interventions for whom referral to an orthopedic surgeon is offered unless contraindication to surgery is documented.
Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have surgery requiring general anesthesia for whom there is management or documentation of the risk of atlanto-axial instability.
Rheumatoid arthritis: percentage of pregnant patients for whom methotrexate and leflunomide are not used.
Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for developing renal insufficiency for whom serum creatinine is assessed at baseline and at least once in the first year following initiation of therapy.
Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for GI bleeding for whom a complete blood count is performed at baseline and during the first year after initiating therapy.
Asian Liver Center at Stanford University(1)
Perinatal care: percentage of newborns delivered from mothers who tested positive for hepatitis B surface antigen (HBsAg) during pregnancy who receive birth doses of hepatitis B virus (HBV) vaccine and hepatitis B immune globulin (HBIG) within 12 hours of delivery.
Atkinson, Mark J, Ph.D.(4)
"Convenience" scale of the Treatment Satisfaction Questionnaire for Medication (TSQM): the mean scale score for the "Convenience" items on the TSQM (version II).
"Effectiveness" scale of the Treatment Satisfaction Questionnaire for Medication (TSQM): the mean scale score for the "Effectiveness" items on the TSQM (version II).
"Global Satisfaction" scale of the Treatment Satisfaction Questionnaire for Medication (TSQM): the mean scale score for the "Global Satisfaction" items on the TSQM (version II).
"Side Effects" scale of the Treatment Satisfaction Questionnaire for Medication (TSQM): the mean scale score for the "Side Effects" items on the TSQM (version II).
Atkinson, Mark J, Ph.D.; Hass, Steven L, Ph.D.(4)
"Convenience" scale of the Treatment Satisfaction Questionnaire for Medication (TSQM): the mean scale score for the "Convenience" items on the TSQM (version II).
"Effectiveness" scale of the Treatment Satisfaction Questionnaire for Medication (TSQM): the mean scale score for the "Effectiveness" items on the TSQM (version II).
"Global Satisfaction" scale of the Treatment Satisfaction Questionnaire for Medication (TSQM): the mean scale score for the "Global Satisfaction" items on the TSQM (version II).
"Side Effects" scale of the Treatment Satisfaction Questionnaire for Medication (TSQM): the mean scale score for the "Side Effects" items on the TSQM (version II).
Australian Council on Healthcare Standards(330)
Access and exit block to the ICU: percentage of appropriate patients referred to an intensive care unit, who are not admitted to the unit because of inadequate resources, during the 6 month time period.
Access and exit block to the ICU: percentage of elective surgical cases deferred or cancelled due to the lack of ICU/HDU bed, during the 6 month time period.
Access and exit block to the ICU: percentage of patients discharged from the intensive care unit (ICU) between 6pm and 6am, during the 6 month time period.
Access and exit block to the ICU: percentage of patients who were transferred to another facility/area/ICU due to unavailability of an ICU bed, during the 6 month time period.
Access and exit block to the ICU: percentage of patients whose discharge from the intensive care unit (ICU) was delayed more than 12 hours, during the 6 month time period.
Access block: percentage of mental health or critical care patients who waited greater than 4 hours in the emergency department (ED) after the time of decision to admit them, during the 6 month time period.
Access block: percentage of patients who were admitted or planned for admission but discharged from the emergency department (ED) without reaching an inpatient bed, transferred to another hospital for admission, or died in the ED whose total ED time exceeded 8 hours, during the 6 month time period.
Acute myocardial infarction (AMI): percentage of patients with an AMI requiring thrombolysis who receive thrombolytic therapy within 1 hour of presentation to the emergency department, as their primary treatment, during the 6 month time period.
Acute myocardial infarction (AMI): percentage of patients with an AMI who receive PTCA as their primary treatment and have balloon inflation within 1 hour of presentation to the emergency department, during the 6 month time period.
Aged care: percentage of general medical patients 65 years and over who have a documented vitamin D deficiency who are prescribed vitamin D, during the 6 month time period.
Aged care: percentage of medical patients 65 years and older who have had their cognition assessed using a validated tool such as the Abbreviated Mental Test Score (AMTS) or Mini Mental State Examination (MMSE), during the 6 month time period.
Aged care: percentage of patients admitted to geriatric medicine or geriatric rehabilitation unit for whom there is documented objective assessment of physical function on admission and at least once more during the inpatient stay, during the 6 month time period.
Anatomical pathology: percentage of validated large biopsy results with a turnaround time (collected to validated time) less than 96 hours, during the 1 to 2 week time period.
Anatomical pathology: percentage of validated large biopsy results with a turnaround time (received to validated time) less than 92 hours, during the 1 to 2 week time period.
Anatomical pathology: percentage of validated small biopsy results with a turnaround time (collected to validated time) less than 48 hours, during the 1 to 2 week time period.
Anatomical pathology: percentage of validated small biopsy results with a turnaround time (received to validated time) less than 44 hours, during the 1 to 2 week time period.
Antibiotic prophylaxis: percentage of patients who undergo hysterectomy who receive antibiotic prophylaxis prior to surgery, during the 6 month time period.
Asthma: the average length of stay for all episodes of children admitted with a primary diagnosis of asthma, during the 6 month time period, excluding same day admissions.
Asthma: the average length of stay for all episodes of children admitted with a primary diagnosis of asthma, during the 6 month time period.
Blood transfusion: percentage of red blood cell (RBC) transfusion episodes when the HB reading is 100g/L or more, during the 6 month time period.
Blood transfusion: percentage of significant adverse transfusion events related to a blood transfusion episode, during the 6 month time period.
Blood transfusion: percentage of transfusion episodes where informed patient consent was not documented, during the 6 month time period.
Cancellation of booked procedures: percentage of patients booked into a day procedure facility who fail to arrive, during the 6 month time period.
Cancellation of booked procedures: percentage of patients booked into a day procedure facility, whose procedure is cancelled after their arrival at the facility, due to a pre-existing medical condition, during the 6 month time period.
Cancellation of booked procedures: percentage of patients booked into a day procedure facility, whose procedure is cancelled after their arrival at the facility, due to administrative/organisational reasons, during the 6 month time period.
Cancellation of booked procedures: percentage of patients booked into a day procedure facility, whose procedure is cancelled after their arrival at the facility, due to an acute medical condition, during the 6 month time period.
Cardiothoracic surgery: percentage of elective patients who die in the same admission as having coronary artery graft surgery (CAGS), during the 6 month time period.
Cardiothoracic surgery: percentage of patients aged 71 years or greater who die in the same admission as having coronary artery graft surgery (CAGS), during the 6 month time period.
Cardiothoracic surgery: percentage of patients who die in the same admission as having coronary artery graft surgery (CAGS), during the 6 month time period.
Cardiovascular disease: percentage of inpatients undergoing coronary artery bypass grafts within 24 hours of percutaneous transluminal coronary angioplasty (PCTA) (with or without stenting) in the same admission, during the 6 month time period.
Cardiovascular disease: percentage of patients discharged with a diagnosis of congestive heart failure and atrial fibrillation who have no contraindication to the use of warfarin, who are prescribed warfarin, during the 6 month time period.
Cardiovascular disease: percentage of patients discharged with a diagnosis of congestive heart failure who have no contraindications to the use of an ACE Inhibitor (ACEI) or Angiotensin II Receptor Antagonist (A2RA) who are prescribed an ACEI or A2RA, during the 6 month time period.
Cardiovascular disease: percentage of patients discharged with a diagnosis of congestive heart failure who have no contraindications to the use of beta blockers and who are prescribed beta blocker therapy, during the 6 month time period.
Cardiovascular disease: percentage of patients discharged with any diagnosis of congestive heart failure who are referred for chronic disease management service that includes physical rehabilitation, during the 6 month time period.
Cardiovascular disease: percentage of patients with acute myocardial infarction (AMI) requiring thrombolysis who receive thrombolytic therapy within 1 hour of presentation to the hospital, during the 6 month time period.
Cardiovascular disease: percentage of vessels in which percutaneous transluminal coronary angioplasty (PTCA) (with or without stenting) is undertaken where primary success, as defined, is achieved, during the 6 month time period.
Care planning: percentage of carers involved in developing care plans, during the 6 month time period.
Care planning: percentage of consumers with current completed care plans (including consumer involvement and signature) in the file, during the 6 month time period.
Cataract surgery: percentage of patients having a discharge intention of 1 day, who had an overnight admission following cataract surgery, during the 6 month time period.
Cataract surgery: percentage of patients having a readmission within 28 days of discharge following cataract surgery, due to endophthalmitis in the operated eye, during the 6 month time period.
Cataract surgery: percentage of patients having an anterior vitrectomy at the time of cataract surgery, during the 6 month time period.
Cataract surgery: percentage of readmissions (related to the operated eye) within 28 days of discharge following cataract surgery, during the 6 month time period.
Central line-associated blood stream infection (CLAB) rate: percentage of adult intensive care units (ICU)-associated centrally-inserted central line-associated blood stream infection (CI-CLAB), during the 6 month time period.
Central line-associated blood stream infection (CLAB) rate: percentage of adult intensive care units (ICU)-associated peripherally-inserted central line-associated blood stream infection (PI-CLAB), during the 6 month time period.
Central line-associated blood stream infection (CLAB) rate: percentage of paediatric intensive care unit (ICU)-associated centrally-inserted central line-associated blood stream infection (CI-CLAB), during the 6 month time period.
Central line-associated blood stream infection (CLAB): percentage of haematology unit-related centrally-inserted central line-associated blood stream infection (CI-CLAB), during the 6 month time period.
Central line-associated blood stream infection (CLAB): percentage of haematology unit-related peripherally-inserted central line-associated blood stream infection (PI-CLAB), during the 6 month time period.
Central line-associated blood stream infection (CLAB): percentage of oncology unit-related centrally-inserted central line-associated blood stream infection (CI-CLAB), during the 6 month time period.
Central line-associated blood stream infection (CLAB): percentage of oncology unit-related peripherally-inserted central line-associated blood stream infection (PI-CLAB), during the 6 month time period.
Central line-associated blood stream infection (CLAB): percentage of outpatient intravenous therapy (OPIV) unit-related centrally-inserted central line-associated blood stream infection (CI-CLAB), during the 6 month time period.
Central line-associated blood stream infection (CLAB): percentage of outpatient intravenous therapy (OPIV) unit-related peripherally-inserted central line-associated blood stream infection (PI-CLAB), during the 6 month time period.
Central line-associated blood stream infection (CLAB): percentage of paediatric intensive care unit (ICU)-associated peripherally-inserted central line-associated blood stream infection (PI-CLAB), during the 6 month time period.
Central line-utilisation ratio (CLUR): number of centrally-inserted (CI) central line-days per patient-days in adult intensive care unit (ICU), during the 6 month time period.
Central line-utilisation ratio (CLUR): number of centrally-inserted (CI) central line-days per patient-days in paediatric intensive care unit (ICU), during the 6 month time period.
Central line-utilisation ratio (CLUR): number of peripherally-inserted (PI) central line-days per patient-days in adult intensive care unit (ICU), during the 6 month time period.
Central line-utilisation ratio (CLUR): number of peripherally-inserted (PI) central line-days per patient-days in paediatric intensive care unit (ICU), during the 6 month time period.
Chemical pathology: percentage of serum/plasma potassium validated report results for ED (or requests specified as urgent) with a turnaround time (received to validated time) less than 60 minutes, during the 2 to 4 week time period.
Colonoscopy: percentage of incomplete colonoscopies performed, during the 6 month time period.
Colonoscopy: percentage of patients treated for possible perforation NOT related to polypectomy, during the 6 month time period.
Colonoscopy: percentage of patients treated for possible perforation who have had a polypectomy performed, during the 6 month time period.
Colonoscopy: percentage of patients who have bleeding, during the 6 month time period.
Complications of sedation: percentage of patients who have an endoscopy procedure involving sedation who are transferred or admitted for an overnight stay as a result of aspiration, during the 6 month time period.
Day of surgery admissions: percentage of elective surgery patients admitted to the organisation on the day of surgery, during the 6 month time period.
Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients who have an unplanned extension to the time between entry into the post-anaesthesia care unit to the meeting of hospital/day surgery discharge criteria, during the time period under study.
Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients who have received a pre-anaesthesia assessment before the day of day surgery, during the time period under study.
Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients whose procedure is cancelled on the day of surgery for anaesthetic reasons other than an acute medical condition, during the time period under study.
Day surgery anaesthesia care: percentage of patients receiving anaesthesia care as day-stay surgery patients with unplanned overnight admissions for anaesthetic reasons, during the time period under study.
Dermatological consult: percentage of patients who receive a dermatological consult within 24 hours, greater than or equal to 1 day and less than 2 days, greater than or equal to 2 days and less than 5 working days, or longer than one week after the primary contact time to assessment visit, during the 6 month time period.
Endocrine disease: percentage of insulin treated diabetic inpatients having an elective operation, and a length of stay greater than or equal to 48 hours, whose medical record shows at least 4 blood glucose measurements on the first post-operative day, during the 6 month time period.
Endocrine disease: percentage of insulin treated diabetic inpatients having an elective operation, and a length of stay greater than or equal to 48 hours, with a recorded blood glucose level less than 4 mmol/L in the post-operative period, during the 6 month time period.
Endocrine disease: percentage of patients admitted with diabetes having assessment of lower limbs according to guidelines, during the 6 month time period.
Gastrointestinal disease: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion and endoscopic therapy, who subsequently have an operation, during the 6 month time period.
Gastrointestinal disease: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion and have a gastroscopy within 24 hours of admission, during the 6 month time period.
Gastrointestinal disease: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion and subsequently die, during the 6 month time period.
Gastrointestinal disease: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion, and have an operation, during the same admission, during the 6 month time period.
Gastrointestinal disease: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion, for which there is documented evidence that a member of the surgical staff has been notified of their condition, during the 6 month time period.
Gastrointestinal disease: percentage of patients admitted to hospital with haematemesis and/or melaena, who receive a blood transfusion, who are discharged with a specific diagnosis that explains the cause of bleeding, during the 6 month time period.
Gastroscopy: percentage of patients treated for possible perforation related to oesophageal dilatation, during the 6 month time period.
Gastroscopy: percentage of patients undergoing gastroscopies (without dilations or polypectomies) who were treated for possible perforation secondary to instrument related causes, during the 6 month time period.
Gastroscopy: percentage of patients undergoing upper gastrointestinal tract polypectomies treated for possible perforation related to polypectomy, during the 6 month time period.
General surgery: percentage of patients having a laparoscopic cholecystectomy with a bile duct injury requiring operative intervention, during the 6 month time period.
Glaucoma surgery: percentage of patients having a readmission within 28 days of discharge following glaucoma surgery, due to endophthalmitis in the operated eye, during the 6 month time period.
Glaucoma surgery: percentage of patients with a total length of stay (LOS) greater than 3 days following glaucoma surgery, during the 6 month time period.
Glaucoma surgery: percentage of readmissions (related to the operated eye) within 28 days of discharge following glaucoma surgery, during the 6 month time period.
Haematology: percentage of Coag validated report results from ED with a turnaround time (collected to validated time) less than 60 minutes, during the 2 to 4 week time period.
Haematology: percentage of Coag validated report results from ED with a turnaround time (received to validated time) less than 40 minutes, during the 2 to 4 week time period.
Haematology: percentage of haemoglobin validated report results from ED with a turnaround time (collected to validated time) less than 60 minutes, during the 2 to 4 week time period.
Haematology: percentage of haemoglobin validated report results from ED with a turnaround time (received to validated time) less than 40 minutes, during the 2 to 4 week time period.
Haemodialysis-associated blood stream infection: percentage of AV-fistula access-associated blood stream infections, during the 6 month time period.
Haemodialysis-associated blood stream infection: percentage of centrally inserted cuffed line access-associated blood stream infections, during the 6 month time period.
Haemodialysis-associated blood stream infection: percentage of centrally inserted non-cuffed line access-associated blood stream infections, during the 6 month time period.
Haemodialysis-associated blood stream infection: percentage of native vessel graft access-associated blood stream infections, during the 6 month time period.
Haemodialysis-associated blood stream infection: percentage of synthetic graft access-associated blood stream infections, during the 6 month time period.
Healthcare-associated MRSA: percentage of intensive care unit (ICU)-associated new methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections in a non-sterile site, during the 6 month time period.
Healthcare-associated MRSA: percentage of intensive care unit (ICU)-associated new methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections in a sterile site, during the 6 month time period.
Healthcare-associated MRSA: percentage of non-intensive care unit (ICU)-associated new methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections in a non-sterile site, during the 6 month time period.
Healthcare-associated MRSA: percentage of non-intensive care unit (ICU)-associated new methicillin-resistant Staphylococcus aureus (MRSA) inpatient healthcare-associated infections in a sterile site, during the 6 month time period.
Hospital in the home: percentage of patients having 1 unscheduled staff callout during their Hospital in the Home admission, during the 6 month time period.
Hospital in the home: percentage of patients having more than 1 unscheduled staff callout during their Hospital in the Home admission, during the 6 month time period.
Hospital in the home: percentage of patients making 1 unexpected telephone call during their Hospital in the Home admission, during the 6 month time period.
Hospital in the home: percentage of patients making more than 1 unexpected telephone call during their Hospital in the Home admission, during the 6 month time period.
Injury to a major viscus: percentage of patients suffering injury to a major viscus with repair, during a gynaecological operative procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.
Intensive care patient treatment: percentage of patients receiving thromboembolism prophylaxis treatment within 24 hours of admission to the intensive care unit (ICU), during the 6 month time period.
Intra-operative period: percentage of patients receiving a blood transfusion in accordance with National Health and Medical Research Council (NH & MRC) guidelines during a surgical procedure with an anaesthetist in attendance, during the time period under study.
Intra-operative period: percentage of patients undergoing a procedure with an anaesthetist in attendance, who have documented evidence of intra-operative cardiac dysrhythmia/arrest, during the time period under study.
Intra-operative period: percentage of patients who undergo a procedure with an anaesthetist in attendance, where the anaesthesia records substantially complies with the Australian and New Zealand College of Anaesthetists (ANZCA) requirements for the anaesthetic record, during the time period under study.
Intra-operative period: percentage of patients who undergo a procedure with an anaesthetist in attendance, where there is an assistant to an anaesthetist, during the time period under study.
Laparoscopic management of an ectopic pregnancy: percentage of patients having laparoscopic management following an ectopic pregnancy, during the 6 month time period.
Laparoscopic surgery: percentage of patients receiving a bladder injury at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.
Laparoscopic surgery: percentage of patients receiving a ureter injury at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.
Laparoscopic surgery: percentage of patients receiving an injury to a major viscus with repair, during a laparoscopic gynaecological operative procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.
Management of acute pain: percentage of nurses involved in the care of patients with acute pain who have read acute pain protocols, during the time period under study.
Management of acute pain: percentage of nurses involved in the care of patients with acute pain who have received education regarding acute pain management, during the time period under study.
Management of acute pain: percentage of patients having neuraxial, or plexus block analgesic technique, demonstrating neurological dysfunction three months post-procedure secondary to neuraxial technique or plexus block.
Management of acute pain: percentage of patients receiving acute pain management developing severe hypotension, requiring an alteration to or change of analgesic technique, during acute pain management, during the time period under study.
Management of acute pain: percentage of patients receiving acute pain management developing severe respiratory depression requiring naloxone administration during acute pain management, during the time period under study.
Management of acute pain: percentage of patients receiving acute pain management who are satisfied with their current pain relief, during the time period under study.
Management of acute pain: percentage of patients receiving acute pain management with analgesia adequate to allow acute rehabilitation (e.g., effective cough, mobilisation), during the time period under study.
Management of acute pain: percentage of patients receiving acute pain management with pain intensity scores regularly recorded by nursing staff, during the time period under study.
Management of acute pain: percentage of patients receiving neuraxial blockade as part of their acute pain management who develop an epidural abscess or epidural haematoma following neuraxial blockade, during the time period under study.
Management of acute pain: percentage of patients reporting nausea and vomiting whilst receiving acute pain management who are prescribed antiemetic treatment, during the time period under study.
Medication safety: percentage of medication orders that include error-prone abbreviations.
Medication safety: percentage of patients whose known adverse drug reactions are documented on the current medication chart.
Mental health community: percentage of consumers or nominated carers with 3 or more face-to-face contacts within a 7 day period.
Mental health community: percentage of consumers or nominated carers with greater than 24 treatment days over a three month period.
Mental health community: percentage of consumers who were admitted to the hospital for psychiatric reasons (by that service) once or more in the first year of treatment.
Mental health community: percentage of registered consumers seen face-to-face by the community service, during the 6 month time period.
Mental health inpatient: percentage of acute inpatients undergoing non-maintenance electroconvulsive therapy (ECT) of more than 12 treatments, during the 6 month time period.
Mental health inpatient: percentage of episodes of seclusion among inpatient separations having seclusion, during the 6 month time period.
Mental health inpatient: percentage of inpatient separations having physical restraint who experience major complications while under restraint, during the 6 month time period.
Mental health inpatient: percentage of inpatient separations having seclusion who experience major complications while in seclusion, during the 6 month time period.
Mental health inpatient: percentage of inpatient separations having seclusion who were not reviewed by sight, by a medical practitioner or nurse on at least a half-hourly basis, during the 6 month time period.
Mental health inpatient: percentage of inpatient separations who had seclusion for more than 4 hours in 1 episode, during the 6 month time period.
Mental health inpatient: percentage of inpatient separations with a diagnosis on hospital discharge, which is recorded in the medical record, during the 6 month time period.
Mental health inpatient: percentage of inpatient separations with an individual care plan, which is constructed and regularly reviewed with the consumer, during the 6 month time period.
Mental health inpatient: percentage of inpatient separations with at least 1 episode of seclusion, in an admission, during the 6 month time period.
Mental health inpatient: percentage of inpatient separations with at least 2 episodes of seclusion, in an admission or in a 1 month period of an extended admission, during the 6 month time period.
Mental health inpatient: percentage of inpatient separations with at least one episode of physical restraint, during the 6 month time period.
Mental health inpatient: percentage of inpatients allocated a diagnosis within 24 hours of admission, during the 6 month time period.
Mental health inpatient: percentage of inpatients experiencing major medical complications while undergoing electroconvulsive therapy (ECT) excluding maintenance ECT, during the 6 month time period.
Mental health inpatient: percentage of inpatients in the acute unit with a length of stay greater than 30 days, during the 6 month time period.
Mental health inpatient: percentage of inpatients on 3 or more psychotropic medications from 1 sub-group category specified, at the time of discharge, during the 6 month time period.
Mental health inpatient: percentage of inpatients who have a discharge summary or letter, at the time of hospital discharge, during the 6 month time period.
Mental health inpatient: percentage of inpatients who have a final discharge summary recorded in the medical record within 2 weeks of hospital discharge, during the 6 month time period.
Mental health inpatient: percentage of inpatients who have a multidisciplinary review recorded every 3 months, during the 6 month time period.
Mental health inpatient: percentage of inpatients with a complete documented physical examination within 48 hours of admission, during the 6 month time period.
Mental health inpatient: percentage of voluntary inpatient admissions, during the 6 month time period.
Microbiology: percentage of validated CSF results from ED for microscopy (+/- gram stain) with a turnaround time (collected to validated time) less than 60 minutes, during the 1 to 2 month time period.
Microbiology: percentage of validated CSF results from ED with a microscopy (+/- gram stain) with a turnaround time (received to validated time) less than 40 minutes, during the 1 to 2 month time period.
Monitoring of warfarin: percentage of non same-day separations receiving warfarin as an inpatient who die as a result of an adverse drug reaction, during the 6 month time period.
Monitoring of warfarin: percentage of non same-day separations receiving warfarin as an inpatient who experience a cerebral haemorrhage, during the 6 month time period.
Monitoring of warfarin: percentage of non same-day separations receiving warfarin as an inpatient who experience abnormal bleeding, during the 6 month time period.
Monitoring of warfarin: percentage of non same-day separations receiving warfarin as an inpatient with an international normalized ratio (INR)/prothrombin reading greater than 5, during the 6 month time period.
Monitoring of warfarin: percentage of patients on hospital initiated warfarin who receive written drug information on discharge, during the 6 month time period.
Monitoring of warfarin: percentage of patients with an international normalized ratio (INR) result above the therapeutic range who have had their dosage reviewed prior to the next warfarin administration, during the 6 month time period.
Morbidity of radiological procedures: percentage of patients experiencing iodinated contrast extravasation requiring medical review during an IV contrast enhanced CT procedure, during the 6 month period.
Morbidity of radiological procedures: percentage of patients undergoing percutaneous transpleural biopsy of the lung or mediastinum, for whom there is documented evidence of pneumothorax and/or haemothorax requiring intervention following the procedure, during the 6 month period.
Morbidity of radiological procedures: percentage of peripheral embolic complications during angioplasty of the arteries in upper or lower limbs, during the 6 month period.
Morbidity of radiological procedures: percentage of puncture site complications during or following angiography, during the 6 month period.
Neonatal infections: percentage of babies of birth weight less than 1000 grams admitted to the neonatal intensive care unit (NICU) during the time period under study who have a significant blood infection occurring more than 48 hours after birth at any time during their whole admission.
Neonatal infections: percentage of babies of greater than or equal to 1000 grams birth weight, admitted to the neonatal intensive care unit (NICU) during the time period under study who have a significant blood infection occurring more than 48 hours after birth at any time during their whole admission.
Neonatal infections: percentage of live babies born at the reporting hospital who develop blood stream and/or cerebrospinal fluid (CSF) infection within 48 hours of birth and who were born in the 6 month time period.
Neonatal infections: percentage of live babies of greater than or equal to 37 weeks estimated gestational age at birth (GA) born at the reporting hospital who develop a blood and/or cerebrospinal fluid (CSF) infection within 48 hours of birth and who were born in the 6 month time period.
Neonatal infections: percentage of significant blood infections in neonatal intensive care unit (NICU) admitted babies of greater than or equal to 1000 grams birth weight, occurring more than 48 hours of birth, during the 6 month time period.
Neonatal infections: percentage of significant blood infections in neonatal intensive care unit (NICU) admitted babies of less than 1000 grams birth weight, occurring more than 48 hours of birth, during the 6 month time period.
Neurological disease: percentage of inpatients separated from hospital with a discharge diagnosis of stoke that had a documented CT scan, during the 6 month time period.
Neurosurgery: percentage of patients having a neurosurgical infection in hospital, excluding superficial wound infections, requiring nothing more than a single short course of antibiotics, during the 6 month time period.
Neurosurgery: percentage of patients with a new neurological deficit following a neurosurgery procedure, during the 6 month time period.
Obstetric anaesthesia care: percentage of obstetric patients receiving epidural/spinal/combined spinal-epidural procedures in the labour ward for whom there is documented evidence of informed consent for labour ward epidural/spinal analgesia, during the time period under study.
Obstetric anaesthesia care: percentage of obstetric patients receiving epidural/spinal/combined spinal-epidural procedures who experience a post-dural puncture headache, during the time period under study.
Obstetric anaesthesia care: percentage of patients requiring immediate lower segment Caesarean section (LSCS) who deliver within 30 minutes of request for immediate LSCS, during the time period under study.
Obstetric anaesthesia care: percentage of patients undergoing lower segment Caesarean section (LSCS) who receive a general anaesthetic for LSCS, during the time period under study.
Obstetrics: percentage of deliveries with birth weight less than 2750g at 40 weeks gestation or beyond.
Obstetrics: percentage of high risk women undergoing caesarean section who receive appropriate pharmacological thromboprophylaxis.
Obstetrics: percentage of inborn term babies transferred/admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital abnormality.
Obstetrics: percentage of selected primipara sustaining a perineal tear and NO episiotomy.
Obstetrics: percentage of selected primipara undergoing caesarean section.
Obstetrics: percentage of selected primipara undergoing episiotomy and NO perineal tear while giving birth vaginally.
Obstetrics: percentage of selected primipara undergoing episiotomy AND sustaining a perineal tear while giving birth vaginally.
Obstetrics: percentage of selected primipara undergoing surgical repair of the perineum for fourth degree tear.
Obstetrics: percentage of selected primipara undergoing surgical repair of the perineum for third degree tear.
Obstetrics: percentage of selected primipara who have a spontaneous vaginal birth.
Obstetrics: percentage of selected primipara who undergo an instrumental vaginal birth.
Obstetrics: percentage of selected primipara who undergo induction of labour.
Obstetrics: percentage of selected primipara with an intact perineum.
Obstetrics: percentage of serious adverse events that are addressed within a peer review process.
Obstetrics: percentage of term babies born with an Apgar score of less than 7 at five minutes post delivery.
Obstetrics: percentage of women delivering vaginally following a previous primary caesarean section.
Obstetrics: percentage of women having a general anaesthetic for caesarean section.
Obstetrics: percentage of women who give birth vaginally who require a blood transfusion during the same admission.
Obstetrics: percentage of women who receive an appropriate prophylactic antibiotic at the time of caesarean section.
Obstetrics: percentage of women who undergo a caesarean section who require a blood transfusion during the same admission.
Occupational exposure: percentage of reported non-parenteral exposures sustained by staff, during the 6 month time period.
Occupational exposure: percentage of reported parenteral exposures sustained by staff, during the 6 month time period.
Oncology: percentage of pre-menopausal patients with stage II carcinoma of the breast for whom there is documented evidence of treatment, or intention to treat, with polychemotherapy, during the 6 month time period.
Oral health - children: percentage of deciduous teeth extracted (for pathological reasons) within 6 months following pulpotomy treatment, during the time period under study.
Oral health - children: percentage of teeth requiring re-treatment (restoration, endodontic or extraction, but not including Pit & Fissure Sealants) within 24 months of the initial fissure sealant treatment.
Oral health - children: percentage of teeth requiring repeat fissure sealant treatment within 24 months of the initial fissure sealant treatment.
Oral health: percentage of attendances for complications within 7 days of routine extraction, during the time period under study.
Oral health: percentage of attendances for complications within 7 days of surgical extraction, during the time period under study.
Oral health: percentage of completed courses of endodontic treatment on the same tooth within 6 months of initial treatment, during the time period under study.
Oral health: percentage of new patients aged 65 years and over who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.
Oral health: percentage of new patients aged 65 years and over who had intraoral films taken as part of the first general course of care, during the time period under study.
Oral health: percentage of new patients aged under 18 years who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.
Oral health: percentage of new patients aged under 18 years who had intraoral films taken as part of the first general course of care, during the time period under study.
Oral health: percentage of new patients in the age bracket 18 to 24 years who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.
Oral health: percentage of new patients in the age bracket 18 to 24 years who had intraoral films taken as part of the first general course of care, during the time period under study.
Oral health: percentage of new patients in the age bracket 25 to 64 years who had an orthopantomogram (OPG) film taken or ordered as part of the first general course of care, during the time period under study.
Oral health: percentage of new patients in the age bracket 25 to 64 years who had intraoral films taken as part of the first general course of care, during the time period under study.
Oral health: percentage of patients with completed and updated medical history, during the time period under study.
Oral health: percentage of patients with completed charting at initial assessment for general course of care, during the time period under study.
Oral health: percentage of radiographs (bite-wing) that meet all of the 6 criteria (as outlined), during the time period under study.
Oral health: percentage of same denture type (full or partial) and same arch remade within 12 months, during the time period under study.
Oral health: percentage of teeth extracted within 12 months of completing a course of endodontic treatment, during the time period under study.
Oral health: percentage of teeth retreated between 1 and 6 months of completing a course of endodontic treatment, during the time period under study.
Oral health: percentage of teeth retreated within 6 months of an episode of restorative treatment, during the time period under study.
Orthopaedic surgery: percentage of patients undergoing primary total hip joint replacement (THJR) having a postoperative in hospital infection, during the 6 month time period.
Otolaryngology: percentage of patients who have a significant reactionary haemorrhage following tonsillectomy, during the 6 month time period.
Paediatric immunisation: percentage of infants admitted as inpatients for whom there is documented current immunisation status, during the 6 month time period.
Paediatric immunisation: percentage of infants admitted as inpatients with not up to date immunisation status for whom there is documented evidence that they were either given catch up immunisations; or that such immunisation was planned, during the 6 month time period.
Paediatric intensive care unit (ICU) access: percentage of appropriate patients referred to an ICU, who are not admitted to the unit because of inadequate resources, during the 6 month time period.
Paediatric intensive care unit (ICU) access: percentage of elective surgical cases deferred or cancelled due to lack of ICU/HDU bed, during the 6 month time period.
Paediatric intensive care unit (ICU) access: percentage of patients discharged from the ICU between 6PM and 6AM, during the 6 month time period.
Paediatric intensive care unit (ICU) access: percentage of patients who were transferred to another facility/area/ICU due to unavailability of an ICU bed, during the 6 month time period.
Paediatric intensive care unit (ICU) access: percentage of patients whose discharge from the ICU was delayed more than 12 hours, during the 6 month time period.
Paediatric surgery: percentage of children with a pre-operative diagnosis of acute appendicitis, who undergo appendicectomy with normal histology, but significant other intra-abdominal pathology, during the 6 month time period.
Paediatric surgery: percentage of children with a pre-operative diagnosis of acute appendicitis, who undergo appendicectomy with normal histology, during the 6 month time period.
Paediatric surgery: percentage of patients having a pyloromyotomy in which mucosal perforation occurs and is detected at the time of the operation or later, during the 6 month time period.
Patient deaths: percentage of patient deaths addressed within a clinical audit process, during the 6 month time period.
Patient recovery period: percentage of patients undergoing a procedure who are reviewed by an anaesthetist to manage severe pain, not responding to post-anaesthesia care unit (PACU) protocol, in the recovery period, during the time period under study.
Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for a temperature recorded in the recovery period of less than 35 degrees Celsius, during the time period under study.
Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for cardiovascular reasons, in the recovery period, during the time period under study.
Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for post-operative nausea and vomiting not responding to post-anaesthesia care unit (PACU) protocol, in the recovery period, during the time period under study.
Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist for respiratory or cardiac arrest, in the recovery period, during the time period under study.
Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist to relieve respiratory distress, in the recovery period, during the time period under study.
Patient recovery period: percentage of patients undergoing a procedure who receive an intervention by an anaesthetist to treat inadequate reversal of neuro-muscular blockade, in the recovery period, during the time period under study.
Phototherapy: percentage of patients receiving broad band UVB phototherapy, during the 6 month time period.
Phototherapy: percentage of patients receiving narrow band UVB phototherapy, during the 6 month time period.
Phototherapy: percentage of patients receiving UVB phototherapy for eczema, during the 6 month time period.
Phototherapy: percentage of patients receiving UVB phototherapy for other dermatoses, during the 6 month time period.
Phototherapy: percentage of patients receiving UVB phototherapy for psoriasis, during the 6 month time period.
Phototherapy: percentage of patients receiving UVB phototherapy where a protocol for dose and documentation of side effects were used, during the 6 month time period.
Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of the explanation of phototherapy and side effects, during the 6 month time period.
Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of the total UVB dose administered, during the 6 month time period.
Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of treatment outcome at the conclusion of the phototherapy course, during the 6 month time period.
Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence of written informed consent, during the 6 month time period.
Phototherapy: percentage of patients receiving UVB phototherapy where there is documented evidence that contraindications were considered, during the 6 month time period.
Plastic surgery: percentage of completely excised malignant skin tumors, during the 6 month time period.
Post-operative period: percentage of patients receiving anaesthesia care having an unplanned admission to an intensive care or high dependency unit within 24 hours of a procedure with an anesthetist in attendance, during the time period under study.
Post-operative period: percentage of patients who undergo a procedure with an anaesthetist in attendance, for which there is documented evidence of a post anaesthesia review, or other process as determined by the anaesthetic department, during the time period under study.
Pre-anaesthesia period: percentage of patients receiving anaesthesia care in whom it is judged that there has been adequate peri-operative management of current medications (e.g., diabetic medication), during the time period under study.
Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have consent for the administration of anaesthesia or sedation documented in the patient chart, during the time period under study.
Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have received information about the risks associated with the anaesthesia technique, as documented in the patient chart, during the time period under study.
Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have received written information on the anaesthesia technique, as documented in the patient chart, during the time period under study.
Pre-anaesthesia period: percentage of patients receiving anaesthesia care who have received written, verbal, or visual information on the anaesthesia technique, as documented in the patient chart, during the time period under study.
Pre-anaesthesia period: percentage of patients receiving anaesthesia care who, according to the relevant protocol, qualify for preoperative ECG recording who have undergone an ECG tracing according to the departmental or established protocols, during the time period under study.
Pre-anaesthesia period: percentage of patients receiving anaesthesia care with a history of post operative nausea and vomiting (PONV) to whom a prophylactic anti-emetic has been administered, during the time period under study.
Pre-anaesthesia period: percentage of patients seen for pre-anaesthesia assessment before the day of surgery by an anaesthetist, during the time period under study.
Pre-anaesthesia period: percentage of patients seen for pre-anaesthesia assessment before the day of surgery by the anaesthetist who will be responsible for their anaesthesia care, during the time period under study.
Pre-anaesthesia period: percentage of patients who undergo a procedure with an anaesthetist in attendance who are seen by an anaesthetist before entering the operating theatre suite, anaesthetic room, or procedure room, during the time period under study.
Pre-anaesthesia period: percentage of patients who undergo a procedure with an anaesthetist in attendance who receive an anaesthesia assessment by an anaesthetist, of an appropriate duration, during the time period under study.
Radiation oncology: percentage of curative megavoltage radiotherapy courses provided, where CT planning was utilised, during the 6 month time period.
Radiation oncology: percentage of patients receiving megavoltage radiotherapy using multi-leaf collimators (MLCs), during the 6 month time period.
Radiation oncology: percentage of patients receiving radiotherapy, who have a letter on file to the referring doctor and general practitioner, regarding the current radiotherapy course, during 1 week in May or November.
Radiation oncology: percentage of patients waiting more than 14 days from the date 'ready for care', to the date of commencing radiotherapy, during 1 week in May or November.
Radiation oncology: percentage of patients who had radiotherapy for breast conservation (pT1-3, any nodal staging, M0), during the 6 month time period, who had complete follow-up.
Radiation oncology: percentage of patients who had radiotherapy for glottic cancer (T1-2 N0 M0), during the 6 month time period, who had complete follow-up.
Radiation oncology: percentage of patients who have informed consent recorded in the medical record before receiving radiotherapy, during 1 week in May or November.
Radiation oncology: percentage of patients who receive curative chemoradiotherapy for squamous cell carcinoma (SCC) of the cervix in the definitive or the post-operative setting, during the 6 month time period.
Radiation oncology: percentage of patients with squamous cell carcinoma (SCC) of the oral cavity, oropharynx, hypopharynx and larynx who wait longer than 6 weeks from their definitive surgery to commencing their radiotherapy, during the 6 month time period.
Refractive surgery: percentage of patients having a complication (medical or surgical) within 28 days following excimer laser surgery, during the 6 month time period.
Refractive surgery: percentage of patients having a discharge intention of 1 day, who had an overnight admission following refractive surgery, during the 6 month time period.
Refractive surgery: percentage of patients having a readmission within 28 days of discharge, following refractive surgery, due to endophthalmitis in the operated eye, during the 6 month time period.
Refractive surgery: percentage of patients having an anterior vitrectomy at the time of refractive surgery, during the 6 month time period.
Refractive surgery: percentage of readmissions (related to the operated eye) within 28 days of discharge following refractive surgery, during the 6 month time period.
Rehabilitation medicine: percentage of inpatients for whom there is documented evidence of a functional assessment within 72 hours prior to cessation of an inpatient rehabilitation program, during the 6 month time period.
Rehabilitation medicine: percentage of patients admitted to a rehabilitation unit/facility for whom there is a documented established multidisciplinary rehabilitation plan within 7 days of patient admission, during the 6 month time period.
Rehabilitation medicine: percentage of patients admitted to a rehabilitation unit/facility for whom there is documented evidence of a functional assessment within 72 hours of patient admission, during the 6 month time period.
Rehabilitation medicine: percentage of patients who have completed a rehabilitation program and been discharged to their pre-episode form of accommodation, or a form of accommodation that allows greater independence, during the 6 month time period.
Rehabilitation medicine: percentage of patients who have completed a rehabilitation program and for whom there is documented evidence of functional gain, during the 6 month time period.
Rehabilitation medicine: percentage of separations for which there is an appropriate discharge plan for a patient, during the 6 month time period.
Renal disease: percentage of inpatients having a renal biopsy who subsequently develop macroscopic haematuria in any of their voided urine specimens with 24 hours of the procedure, during the 6 month time period.
Report availability: percentage of reports on radiographic examinations not available to the referring doctor within 24 hours of completion, during the 7 day time period.
Respiratory disease: percentage of patients admitted to hospital with a diagnosis of acute asthma for whom there is documented evidence of an appropriate discharge plan, during the 6 month time period.
Respiratory disease: percentage of patients admitted to hospital with a diagnosis of acute asthma for whom there is documented objective assessment of severity in addition to the initial assessment, which facilitates ongoing inpatient management, during the 6 month time period.
Respiratory disease: percentage of patients admitted to hospital with a diagnosis of acute asthma for whom there is documented objective assessment of severity on initial presentation, during the 6 month time period.
Respiratory disease: percentage of patients discharged from a general medical unit with any diagnosis of COPD who are referred for a chronic disease management service that includes physical rehabilitation, during the 6 month time period.
Retinal detachment surgery: percentage of patients having an unplanned readmission within 28 days of discharge, following retinal detachment surgery, due to endophthalmitis in the operated eye, during the 6 month time period.
Retinal detachment surgery: percentage of patients having an unplanned reoperation on the same eye within 28 days, following retinal detachment surgery, during the 6 month time period.
Retinal detachment surgery: percentage of patients with a total length of stay (LOS) greater than 4 days, following retinal detachment surgery, during the 6 month time period.
Retinal detachment surgery: percentage of unplanned readmissions within 28 days of discharge, following retinal detachment surgery, during the 6 month time period.
Skin tumour pathology (biopsy book): percentage of histopathology specimens taken with a skin tumour working diagnosis, during the 6 month time period.
Skin tumour pathology (biopsy book): percentage of patients for whom management lag time was less than 1 working day, greater than or equal to 1 working day and less than 5 working days, and greater than or equal to 5 working days and less than 2 weeks, during the 6 month time period.
Skin tumour pathology (biopsy book): percentage of patients for whom patient information lag time was less than 1 working day, greater than or equal to 1 working day and less than 5 working days, and greater than or equal to 5 working days and less than 2 weeks, during the 6 month time period.
Skin tumour pathology (biopsy book): percentage of patients for whom time to review was less than 2 working days, greater than or equal to 2 working days and less than 5 working days, and greater than or equal to 5 working days and less than 2 weeks, during the 6 month time period.
Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in femoro-popliteal bypass procedures performed, during the 6 month time period.
Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in hip prosthesis procedures performed, during the 6 month time period.
Surgical site infection: percentage of deep incisional surgical site infections (SSIs) in knee prosthesis procedures performed, during the 6 month time period.
Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) (in chest incision site) in coronary artery bypass graft (CABG) procedures performed, during the 6 month time period.
Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) (in the donor incision site) in coronary artery bypass graft (CABG) (involving chest and donor incisions) procedures performed, during the 6 month time period.
Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in abdominal hysterectomy procedures performed, during the 6 month time period.
Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in elective partial or total colectomy procedures (where there is an anastomosis but no stoma formed) performed, during the 6 month time period.
Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in lower segment caesarean section procedures performed, during the 6 month time period.
Surgical site infection: percentage of deep incisional/organ space surgical site infections (SSIs) in open abdominal aortic aneurysm (AAA) procedures performed, during the 6 month time period.
Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) (in chest incision site) in coronary artery bypass graft (CABG) procedures performed, during the 6 month time period.
Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) (in the donor incision site) in coronary artery bypass graft (CABG) (involving chest and donor incisions) procedures performed, during the 6 month time period.
Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in abdominal hysterectomy procedures performed, during the 6 month time period.
Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in elective partial or total colectomy procedures (where there is an anastomosis but no stoma formed) performed, during the 6 month time period.
Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in femoro-popliteal bypass procedures performed, during the 6 month time period.
Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in hip prosthesis procedures performed, during the 6 month time period.
Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in knee prosthesis procedures performed, during the 6 month time period.
Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in lower segment caesarean section procedures performed, during the 6 month time period.
Surgical site infection: percentage of superficial incisional surgical site infections (SSIs) in open abdominal aortic aneurysm (AAA) procedures performed, during the 6 month time period.
Thromboprophylaxis: percentage of high-risk medical patients admitted who receive venous thromboembolism (VTE) prophylaxis, during the 6 month time period.
Thromboprophylaxis: percentage of moderate to high-risk patients (as per guidelines) over 40 years who undergo hysterectomy who receive thromboprophylaxis, during the 6 month time period.
Thromboprophylaxis: percentage of moderate to high-risk patients (as per guidelines) over 40 years who undergo pelvic floor surgery who receive thromboprophylaxis, during the 6 month time period.
Urogynaecology: percentage of patients receiving a bladder injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.
Urogynaecology: percentage of patients receiving a ureter injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.
Urogynaecology: percentage of patients receiving injury to a major viscus with repair, during a pelvic floor repair procedure subsequently up to 2 weeks post-operatively, during the 6 month time period.
Urology: average number of patient days (from the first day after surgery) for all patients having a transurethral resection (TUR) for benign prostatomegaly (excluding patients having other procedures), during the 6 month time period.
Urology: average operating time (minutes) for all patients undergoing a transurethral resection (TUR) for benign prostatomegaly, during the 6 month time period.
Urology: percentage of patients having a transurethral resection (TUR) for benign prostatomegaly, who have a blood transfusion (intra-operatively or post-operatively) within the same admission, during the 6 month time period.
Urology: percentage of patients having an unplanned readmission within 28 days of discharge following transurethral resection (TUR) for benign prostatomegaly, during the 6 month time period.
Vascular surgery: percentage of patients having a carotid endarterectomy who have a stroke within the same admission, during the 6 month time period.
Vascular surgery: percentage of patients having an elective abdominal aortic aneurysm (AAA) repair, who die within the same admission, during the 6 month time period.
Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 1 who are attended to immediately, during the 6 month time period.
Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 2 who are attended to within 10 minutes, during the 6 month time period.
Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 3 who are attended to within 30 minutes, during the 6 month time period.
Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 4 who are attended to within 60 minutes, during the 6 month time period.
Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 5 who are attended to within 120 minutes, during the 6 month time period.
Boston University Health & Disability Research Institute(3)
Post-acute care functional status: mean change score in applied cognitive function of patients in a post-acute care setting as assessed using the "Applied Cognition" domain of the Activity Measure for Post-acute Care (AM-PAC).
Post-acute care functional status: mean change score in basic mobility of patients in a post-acute care setting as assessed using the "Basic Mobility" domain of the Activity Measure for Post-acute Care (AM-PAC).
Post-acute care functional status: mean change score in daily activity of patients in a post-acute care setting as assessed using the "Daily Activities" domain of the Activity Measure for Post-acute Care (AM-PAC).
British Medical Association(77)
Asthma: the percentage of patients aged eight and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility. [NQMC Update Pending]
Asthma: the percentage of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the previous 15 months. [NQMC Update Pending]
Asthma: the percentage of patients with asthma who have had an asthma review in the previous 15 months. [NQMC Update Pending]
Asthma: the practice can produce a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the previous twelve months. [NQMC Update Pending]
Atrial fibrillation: the percentage of patients with atrial fibrillation diagnosed after 1 April 2008 with electrocardiogram (ECG) or specialist confirmed diagnosis. [NQMC Update Pending]
Atrial fibrillation: the percentage of patients with atrial fibrillation who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy. [NQMC Update Pending]
Atrial fibrillation: the practice can produce a register of patients with atrial fibrillation. [NQMC Update Pending]
Cancer: the percentage of patients with cancer diagnosed within the last 18 months who have a patient review recorded as occurring within 6 months of the practice receiving confirmation of the diagnosis. [NQMC Update Pending]
Cancer: the practice can produce a register of all cancer patients defined as a 'register of patients with a diagnosis of cancer excluding nonmelanotic skin cancers from 1 April 2003.' [NQMC Update Pending]
Chronic kidney disease (CKD): the percentage of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less. [NQMC Update Pending]
Chronic kidney disease (CKD): the percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months. [NQMC Update Pending]
Chronic kidney disease (CKD): the percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded). [NQMC Update Pending]
Chronic kidney disease (CKD): the practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD). [NQMC Update Pending]
Chronic obstructive pulmonary disease (COPD): the percentage of all patients with COPD diagnosed after 1st April 2008 in whom the diagnosis has been confirmed by post bronchodilator spirometry. [NQMC Update Pending]
Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]
Chronic obstructive pulmonary disease (COPD): the percentage of patients with COPD with a record of FeV1 in the previous 15 months. [NQMC Update Pending]
Chronic obstructive pulmonary disease (COPD): the practice can produce a register of patients with COPD. [NQMC Update Pending]
Coronary heart disease: the percentage of patients with a history of myocardial infarction (diagnosed after 1 April 2003) who are currently treated with an angiotensin-converting enzyme (ACE) inhibitor or Angiotensin II antagonist. [NQMC Update Pending]
Coronary heart disease: the percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the last 15 months) is 150/90 mm Hg or less. [NQMC Update Pending]
Coronary heart disease: the percentage of patients with coronary heart disease who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded). [NQMC Update Pending]
Coronary heart disease: the percentage of patients with coronary heart disease who have a record of influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]
Coronary heart disease: the percentage of patients with coronary heart disease whose last measured total cholesterol (measured in last 15 months) is 5 mmol/l or less. [NQMC Update Pending]
Coronary heart disease: the percentage of patients with coronary heart disease whose notes have a record of blood pressure in the previous 15 months. [NQMC Update Pending]
Coronary heart disease: the percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months. [NQMC Update Pending]
Coronary heart disease: the percentage of patients with coronary heart disease with a record in the previous 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded). [NQMC Update Pending]
Coronary heart disease: the percentage of patients with newly diagnosed angina (diagnosed after 1 April 2003) who are referred for exercise testing and/or specialist assessment. [NQMC Update Pending]
Coronary heart disease: the practice can produce a register of patients with coronary heart disease. [NQMC Update Pending]
Dementia: the percentage of patients diagnosed with dementia whose care has been reviewed in the previous 15 months. [NQMC Update Pending]
Dementia: the practice can produce a register of patients diagnosed with dementia. [NQMC Update Pending]
Depression: the percentage of patients with a new diagnosis of depression, recorded between the preceding 1 April to 31 March, who have had an assessment of severity at the outset of treatment using an assessment tool validated for use in primary care. [NQMC Update Pending]
Depression: the percentage of patients with diabetes and/or coronary heart disease (CHD) for whom case finding for depression has been undertaken on one occasion during the previous 15 months using two standard screening questions. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes in whom the last blood pressure is 145/85 or less. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes who have a record of HbA1c or equivalent in the previous 15 months. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes who have a record of micro-albuminuria testing in the previous 15 months and the percentage of patients with proteinuria. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes who have a record of retinal screening in the previous 15 months. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes who have a record of the blood pressure in the previous 15 months. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes who have a record of total cholesterol in the previous 15 months. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5 mmol/l or less. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes whose notes record body mass index (BMI) in the previous 15 months. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with angiotensin-converting enzyme (ACE) inhibitors (or angiotensin II [A2] antagonists). [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months. [NQMC Update Pending]
Diabetes mellitus: the percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months. [NQMC Update Pending]
Diabetes mellitus: the practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies whether the patient has Type 1 or Type 2 diabetes. [NQMC Update Pending]
Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have a record of medication review involving the patient and/or carer in the previous 15 months. [NQMC Update Pending]
Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months. [NQMC Update Pending]
Epilepsy: the percentage of patients age 18 years and over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the previous 15 months. [NQMC Update Pending]
Epilepsy: the practice can produce a register of patients age 18 years and over receiving drug treatment for epilepsy. [NQMC Update Pending]
Heart failure: the percentage of patients with a current diagnosis of heart failure due to left ventricular dysfunction (LVD) who are currently treated with angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), who can tolerate therapy and for whom there is no contraindication. [NQMC Update Pending]
Heart failure: the percentage of patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment. [NQMC Update Pending]
Heart failure: the practice can produce a register of patients with heart failure. [NQMC Update Pending]
Hypertension: the percentage of patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 or less. [NQMC Update Pending]
Hypertension: the percentage of patients with hypertension in whom there is a record of the blood pressure in the previous 9 months. [NQMC Update Pending]
Hypertension: the practice can produce a register of patients with established hypertension. [NQMC Update Pending]
Hypothyroidism: the percentage of patients with hypothyroidism with thyroid function tests recorded in the previous 15 months. [NQMC Update Pending]
Hypothyroidism: the practice can produce a register of patients with hypothyroidism. [NQMC Update Pending]
Learning disabilities: the practice can produce a register or patients with learning disabilities. [NQMC Update Pending]
Mental health: the percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months. [NQMC Update Pending]
Mental health: the percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months. [NQMC Update Pending]
Mental health: the percentage of patients on the mental health register who have a comprehensive care plan documented in the records agreed between individuals, their family and/or carers as appropriate. [NQMC Update Pending]
Mental health: the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance. [NQMC Update Pending]
Mental health: the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. [NQMC Update Pending]
Mental health: the practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses. [NQMC Update Pending]
Obesity: the practice can produce a register of patients aged 16 and over with a body mass index (BMI) greater than or equal to 30 in the previous 15 months. [NQMC Update Pending]
Palliative care: the practice has a complete register available of all patients in need of palliative care/support irrespective of age. [NQMC Update Pending]
Palliative care: the practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed. [NQMC Update Pending]
Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), asthma, schizophrenia, bipolar affective disorder or other psychoses who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months. [NQMC Update Pending]
Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the previous 15 months. [NQMC Update Pending]
Stroke and transient ischaemic attack (TIA): the percentage of new patients with a stroke who have been referred for further investigation. [NQMC Update Pending]
Stroke and transient ischaemic attack (TIA): the percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in previous 15 months) is 150/90 or less. [NQMC Update Pending]
Stroke and transient ischaemic attack (TIA): the percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an anti-platelet agent (aspirin, clopidogrel, dipyridamole or a combination), or anti-coagulant is being taken (unless a contraindication or side-effects are recorded). [NQMC Update Pending]
Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have a record of blood pressure in the notes in the preceding 15 months. [NQMC Update Pending]
Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have a record of total cholesterol in the last 15 months. [NQMC Update Pending]
Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March. [NQMC Update Pending]
Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke whose last measured total cholesterol (measured in previous 15 months) is 5 mmol/l or less. [NQMC Update Pending]
Stroke and transient ischaemic attack (TIA): the practice can produce a register of patients with stroke or TIA. [NQMC Update Pending]
CAHPS Consortium(77)
Behavioral health care patients' experiences: percentage of adult patients who rated how much improvement they perceived in themselves.
Behavioral health care patients' experiences: percentage of adult patients who reported how much of a problem they had getting treatment and information from their health plan or managed behavior health organization.
Behavioral health care patients' experiences: percentage of adult patients who reported how much they were helped by the counseling or treatment they received.
Behavioral health care patients' experiences: percentage of adult patients who reported how often their clinicians communicated well.
Behavioral health care patients' experiences: percentage of adult patients who reported how often they get treatment quickly.
Behavioral health care patients' experiences: percentage of adult patients who reported how often they were seen within 15 minutes of their appointment.
Behavioral health care patients' experiences: percentage of adult patients who reported whether anyone shared information regarding their counseling or treatment that should have been kept private.
Behavioral health care patients' experiences: percentage of adult patients who reported whether someone talked to them about including family or friends in their counseling or treatment.
Behavioral health care patients' experiences: percentage of adult patients who reported whether the care they received was responsive to their cultural needs.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they felt they could refuse a specific type of medicine or treatment.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given enough information to manage their condition.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given information about patient rights.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were provided information about treatment options.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about medication side effects.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about other ways to receive treatment after their benefits were used up.
Behavioral health care patients' satisfaction: adult patients' overall rating of the counseling or treatment they received.
Behavioral health care patients' satisfaction: adult patients' overall rating of their health plan for counseling or treatment.
Health plan members' experiences: percentage of adult health plan members who reported how often it was easy for them to get needed care.
Health plan members' experiences: percentage of adult health plan members who reported how often their personal doctor communicated well.
Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.
Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan information and customer service.
Health plan members' experiences: percentage of parents or guardians who reported how often it was easy for them to get needed care for their enrolled child.
Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get prescription medicines for their enrolled children with chronic conditions through their health plan.
Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get specialized services for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child got care quickly.
Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child's personal doctor communicated well.
Health plan members' experiences: percentage of parents or guardians who reported how often they were satisfied with their enrolled child's health plan information and customer service.
Health plan members' experiences: percentage of parents or guardians who reported their experiences with getting needed information about their children's care for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported their experiences with shared decision-making for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported their experiences with their children's personal doctor or nurse for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported they received assistance with coordination of care and services for their enrolled children with chronic conditions.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their health care.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their health plan.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their personal doctor.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their specialist.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health care.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health plan.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's personal doctor.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's specialist.
Hospital inpatients' experiences: adult inpatients' ratings of this hospital.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often the area around their room was quiet at night.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff communicated well about medications.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff was responsive to their needs.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their doctors communicated well.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their nurses communicated well.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their pain was controlled.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their room and bathroom were kept clean.
Hospital inpatients' experiences: percentage of adult inpatients who reported whether they were provided specific discharge information.
Hospital inpatients' experiences: percentage of adult inpatients who reported whether they would recommend this hospital to their friends and family.
In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often their nephrologist cared and communicated well.
In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often they were satisfied with the quality of dialysis center care and operations.
In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported whether specified information was provided to them.
In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center staff.
In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center.
In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their kidney doctors.
Patients' experiences: percentage of adult primary care patients who reported how often it was easy for them to get appointments and needed care.
Patients' experiences: percentage of adult primary care patients who reported how often their doctor's office followed up on results for blood tests, x-rays or any other tests ordered.
Patients' experiences: percentage of adult primary care patients who reported how often their doctor's office staff was courteous and helpful.
Patients' experiences: percentage of adult primary care patients who reported how often their doctors communicated well.
Patients' experiences: percentage of adult specialty care patients who reported how often it was easy for them to get appointments and needed care.
Patients' experiences: percentage of adult specialty care patients who reported how often their doctor's office followed up on results for blood tests, x-rays or any other tests ordered.
Patients' experiences: percentage of adult specialty care patients who reported how often their doctor's office staff was courteous and helpful.
Patients' experiences: percentage of adult specialty care patients who reported how often their doctors communicated well.
Patients' experiences: percentage of parents/guardians who reported how often it was easy for them to get appointments and needed care for their child.
Patients' experiences: percentage of parents/guardians who reported how often it was easy for them to get appointments and needed care for their child.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor communicated well.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor communicated well.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office followed up on results for blood tests, x-rays or any other tests ordered.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office followed up on results for blood tests, x-rays or any other tests ordered.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office staff was courteous and helpful.
Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office staff was courteous and helpful.
Patients' experiences: percentage of parents/guardians who reported whether their child's doctor addressed their child's growth and development.
Patients' experiences: percentage of parents/guardians who reported whether their child's doctor gave advice on keeping their child safe and healthy.
Patients' satisfaction with care: adult primary care patient's overall rating of their doctor.
Patients' satisfaction with care: adult specialty care patient's overall rating of their doctor.
Patients' satisfaction with care: parent's/guardian's overall rating of their child's doctor.
Patients' satisfaction with care: parent's/guardian's overall rating of their child's doctor.
Canadian Institute for Health Information(22)
Acute myocardial infarction (AMI): risk-adjusted rate of all cause in-hospital death occurring within 30 days of first admission to an acute care hospital with a diagnosis of AMI. [NQMC Update Pending]
Acute myocardial infarction (AMI): risk-adjusted rate of unplanned readmission following discharge for AMI. [NQMC Update Pending]
Ambulatory care sensitive conditions: age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years. [NQMC Update Pending]
Asthma: risk-adjusted rate of unplanned readmission following discharge for asthma. [NQMC Update Pending]
Caesarean section: proportion of women delivering babies in acute care hospital by Caesarean section. [NQMC Update Pending]
Cardiac revascularization: age-standardized rate of CABG surgery performed on inpatients in acute care hospitals or PCI performed on patients in acute care hospitals, same day surgery facilities or catheterization laboratories, per 100,000 population age 20 years and over. [NQMC Update Pending]
Coronary artery bypass graft (CABG) surgery: age-standardized rate of CABG surgery performed on inpatients in acute care hospitals, per 100,000 population age 20 years and over. [NQMC Update Pending]
Hip fracture: age-standardized acute care hospitalization rate for fracture of the hip, per 100,000 population age 65 and over. [NQMC Update Pending]
Hip fracture: risk adjusted rate of in-hospital hip fracture among acute care inpatients aged 65 years and over, per 1,000 discharges. [NQMC Update Pending]
Hip fracture: risk-adjusted proportion of hip fracture patients aged 65 years and older who underwent hip fracture surgery in an acute care hospital on the day of admission or the next day. [NQMC Update Pending]
Hip fracture: risk-adjusted proportion of hip fracture patients aged 65 years and older who underwent hip fracture surgery in an acute care hospital on the day of admission, the next day or the day after that. [NQMC Update Pending]
Hip replacement surgery: age-standardized rate of unilateral or bilateral hip replacement surgery performed on inpatients in acute care hospitals per 100,000 population age 20 years and over. [NQMC Update Pending]
Hysterectomy: age-standardized rate of hysterectomy provided to patients in acute care hospitals or same-day surgery facilities, per 100,000 women age 20 years and over. [NQMC Update Pending]
Hysterectomy: risk-adjusted rate of unplanned readmission following discharge for hysterectomy. [NQMC Update Pending]
Inflow/outflow: ratio of the number of separations (discharges and deaths) from acute care/same day surgery facilities within a given region by the number of acute care/same day surgery separations generated by residents of that region. [NQMC Update Pending]
Injury: the age-standardized rate of acute care hospitalization due to injury resulting from the transfer of energy (excluding poisoning and other non-traumatic injuries), per 100,000 population. [NQMC Update Pending]
Knee replacement surgery: age-standardized rate of unilateral or bilateral knee replacement surgery performed on patients in acute care hospitals or same-day surgery facilities, per 100,000 population age 20 years and over. [NQMC Update Pending]
Percutaneous coronary interventions (PCI): age-standardized rate of PCI performed on inpatients in acute care hospitals, same day surgery facilities or catheterization laboratories, per 100,000 population age 20 years and over. [NQMC Update Pending]
Physician to population ratio: total number of general physicians and family physicians per 100,000 population. [NQMC Update Pending]
Physician to population ratio: total number of specialist physicians per 100,000 population. [NQMC Update Pending]
Prostatectomy: risk-adjusted rate of unplanned readmission following discharge for prostatectomy. [NQMC Update Pending]
Stroke: risk-adjusted rate of all cause in-hospital death occurring within 30 days of first admission to an acute care hospital with a diagnosis of stroke. [NQMC Update Pending]
Casarett, David, MD, MA; VA Medical Center(1)
Patients' experiences: percentage of veterans who die in an inpatient VA facility (intensive care, acute care, hospice unit, nursing home care unit or community living center) for whom a Bereaved Family Survey (BFS) is completed with at least 78% of items receiving an optimal response.
Center for Health Services Research, University of Colorado, under contract to Centers for Medicare and Medicaid Services(41)
Home health care: percentage of patients discharged to the community.
Home health care: percentage of patients who are confused less often.
Home health care: percentage of patients who get better at bathing.
Home health care: percentage of patients who get better at getting in and out of bed.
Home health care: percentage of patients who get better at taking their medicines correctly (by mouth).
Home health care: percentage of patients who get better at walking or moving around.
Home health care: percentage of patients who get better getting to and from the toilet.
Home health care: percentage of patients who had to be admitted to the hospital.
Home health care: percentage of patients who have less pain when moving around.
Home health care: percentage of patients who need urgent, unplanned medical care.
Home health care: percentage of patients who stay the same or don't get worse at bathing.
Home health care: percentage of patients whose speech and oral (verbal) expression of language improved.
Home health care: percentage of patients whose speech and oral (verbal) expression of language stabilized.
Home health care: percentage of patients with a decrease in the current number of (observable) surgical wounds.
Home health care: percentage of patients with improvement in ability to do laundry.
Home health care: percentage of patients with improvement in ability to shop.
Home health care: percentage of patients with improvement in anxiety frequency.
Home health care: percentage of patients with improvement in behavioral problem frequency.
Home health care: percentage of patients with improvement in bowel incontinence frequency.
Home health care: percentage of patients with improvement in cognitive functioning.
Home health care: percentage of patients with improvement in dressing lower body.
Home health care: percentage of patients with improvement in dressing upper body.
Home health care: percentage of patients with improvement in dyspnea.
Home health care: percentage of patients with improvement in eating.
Home health care: percentage of patients with improvement in grooming.
Home health care: percentage of patients with improvement in housekeeping.
Home health care: percentage of patients with improvement in light meal preparation.
Home health care: percentage of patients with improvement in status of surgical wounds.
Home health care: percentage of patients with improvement in telephone use.
Home health care: percentage of patients with improvement in urinary incontinence.
Home health care: percentage of patients with improvement in urinary tract infection.
Home health care: percentage of patients with stabilization in ability to do laundry.
Home health care: percentage of patients with stabilization in ability to shop.
Home health care: percentage of patients with stabilization in anxiety frequency.
Home health care: percentage of patients with stabilization in cognitive functioning.
Home health care: percentage of patients with stabilization in grooming.
Home health care: percentage of patients with stabilization in housekeeping.
Home health care: percentage of patients with stabilization in light meal preparation.
Home health care: percentage of patients with stabilization in management of oral medications.
Home health care: percentage of patients with stabilization in telephone use.
Home health care: percentage of patients with stabilization in transferring.
Center for Quality Assessment and Improvement in Mental Health(17)
Bipolar disorder: percentage of patients with Bipolar I Disorder with depressive symptoms and behaviors who have evidence of use of a mood stabilizing or antimanic agent during the first 12 weeks of pharmacotherapy treatment.
Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their level-of-functioning in response to treatment.
Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment.
Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are provided with education and information about their illness and treatment within 12 weeks of initiating treatment.
Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an antipsychotic agent who were assessed for the presence of extrapyramidal symptoms twice within the first 24 weeks of treatment.
Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent who receive at least one screening for hyperglycemia within the initial 16 weeks of treatment.
Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with an atypical antipsychotic agent who received at least one assessment for hyperlipidemia within the initial 16 week period of treatment.
Bipolar disorder: the percentage of patients diagnosed with bipolar disorder and treated with lithium who have evidence of a lithium serum medication level with 12 weeks of beginning treatment.
Bipolar disorder: the percentage of patients diagnosed with bipolar disorder who receive an initial assessment that considers the risk of suicide.
Bipolar disorder: the percentage of patients with bipolar disorder who receive a recommendation for an adjunctive psychosocial intervention, including evidence-based therapies, within 12 weeks of initiating treatment.
Bipolar disorder: the percentage of patients with bipolar disorder who receive an initial assessment that considers alcohol and chemical substance use.
Bipolar disorder: the percentage of patients with bipolar disorder who were monitored for weight gain during initial 12 week period of treatment.
Bipolar disorder: the percentage of patients with Bipolar I Disorder symptoms and behaviors who received monotherapy with an antidepressant agent during the first 12 weeks of treatment.
Bipolar disorder: the percentage of patients with Bipolar I Disorder with mania/hypomania, mixed or cycling symptoms and behaviors who have evidence of use of pharmacotherapy agent with antimanic properties during the first 12 weeks of treatment.
Depression: the percentage of patients diagnosed with unipolar depression who receive an initial assessment that considers alcohol and chemical substance use.
Depression: the percentage of patients diagnosed with unipolar depression who receive an initial assessment that considers the risk of suicide.
Depression: the percentage of patients presenting with depression who were assessed, prior to the initiation of treatment, for the presence of prior or current symptoms and/or behaviors associated with mania or hypomania.
Centers for Education and Research on Therapeutics at the University of Alabama at Birmingham(4)
Gout: percentage of patients with gout receiving an initial prescription for allopurinol and have significant renal impairment whose initial daily allopurinol dose is less than 300 mg per day.
Gout: percentage of patients with gout started on urate-lowering therapy who have either a history of nephrolithiasis or significant renal insufficiency who are started on a xanthine oxidase inhibitor as the initial urate-lowering medication rather than a uricosuric agent.
Gout: percentage of patients with hyperuricemia and gouty arthritis who are offered treatment with a urate-lowering drug.
Gout: percentage of patients with tophaceous gout who are given an initial prescription for a urate-lowering medication and lack both significant renal impairment and peptic ulcer disease who had a prophylactic anti-inflammatory agent given concomitantly.
Centers for Medicare & Medicaid Services(159)
Acute myocardial infarction (AMI): 30-day mortality rate.
Acute myocardial infarction (AMI): thirty-day all-cause risk standardized readmission rate following AMI hospitalization.
Acute myocardial infarction/chest pain: median time from emergency department (ED) arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or chest pain patients (with probable cardiac chest pain).
Acute myocardial infarction/chest pain: percentage of emergency department (ED) acute myocardial infarction (AMI) patients or chest pain patients (with probable cardiac chest pain) who received aspirin within 24 hours before ED arrival or prior to transfer.
Acute myocardial infarction: median time from emergency department (ED) arrival to administration of fibrinolytic therapy in ED patients with ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to ED arrival and prior to transfer.
Acute myocardial infarction: median time from hospital arrival to administration of fibrinolytic agent in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]
Acute myocardial infarction: median time from hospital arrival to primary PCI in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]
Acute myocardial infarction: median time to transfer to another facility for acute coronary intervention.
Acute myocardial infarction: percent of patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less. [NQMC Update Pending]
Acute myocardial infarction: percent of patients receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. [NQMC Update Pending]
Acute myocardial infarction: percent of patients who expired during hospital stay. [NQMC Update Pending]
Acute myocardial infarction: percent of patients with a history of smoking cigarettes who receive smoking cessation advice or counseling during the hospital stay. [NQMC Update Pending]
Acute myocardial infarction: percent of patients with documentation of low-density lipoprotein cholesterol (LDL-c) level in the hospital record or documentation that LDL-c testing was done during the hospital stay or is planned for after discharge. [NQMC Update Pending]
Acute myocardial infarction: percent of patients with elevated low-density lipoprotein cholesterol (LDL-c greater than or equal to 100 mg/dL or narrative equivalent) who are prescribed a lipid-lowering medication at hospital discharge. [NQMC Update Pending]
Acute myocardial infarction: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]
Acute myocardial infarction: percent of patients without aspirin contraindications who are prescribed aspirin at hospital discharge. [NQMC Update Pending]
Acute myocardial infarction: percent of patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. [NQMC Update Pending]
Acute myocardial infarction: percent of patients without beta-blocker contraindications who are prescribed a beta-blocker at hospital discharge. [NQMC Update Pending]
Acute myocardial infarction: percentage of emergency department (ED) acute myocardial infarction (AMI) patients receiving fibrinolytic therapy during the ED stay and having a time from ED arrival to fibrinolysis of 30 minutes or less.
Children's asthma care: percent of pediatric asthma inpatients who received relievers during hospitalization.
Children's asthma care: percent of pediatric asthma inpatients who received systemic corticosteroids during hospitalization.
Children's asthma care: percent of pediatric asthma inpatients with documentation that they or their caregivers were given a written Home Management Plan of Care (HMPC) document.
Health plan members' experiences: percentage of adult health plan members who reported how often it was easy for them to get needed care.
Health plan members' experiences: percentage of adult health plan members who reported how often their personal doctor communicated well.
Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.
Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan information and customer service.
Health plan members' experiences: percentage of parents or guardians who reported how often it was easy for them to get needed care for their enrolled child.
Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child got care quickly.
Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child's personal doctor communicated well.
Health plan members' experiences: percentage of parents or guardians who reported how often they were satisfied with their enrolled child's health plan information and customer service.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their health care.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their health plan.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their personal doctor.
Health plan members' satisfaction with care: adult health plan members' overall ratings of their specialist.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health care.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health plan.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's personal doctor.
Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's specialist.
Heart failure (HF): 30-day mortality rate.
Heart failure (HF): thirty-day all-cause risk standardized readmission rate following HF hospitalization.
Heart failure: percent of patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. [NQMC Update Pending]
Heart failure: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]
Heart failure: percent of patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. [NQMC Update Pending]
Heart failure: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]
Home health care: percentage of patients discharged to the community.
Home health care: percentage of patients who are confused less often.
Home health care: percentage of patients who get better at bathing.
Home health care: percentage of patients who get better at getting in and out of bed.
Home health care: percentage of patients who get better at taking their medicines correctly (by mouth).
Home health care: percentage of patients who get better at walking or moving around.
Home health care: percentage of patients who get better getting to and from the toilet.
Home health care: percentage of patients who had to be admitted to the hospital.
Home health care: percentage of patients who have less pain when moving around.
Home health care: percentage of patients who need urgent, unplanned medical care.
Home health care: percentage of patients who stay the same or don't get worse at bathing.
Home health care: percentage of patients whose speech and oral (verbal) expression of language improved.
Home health care: percentage of patients whose speech and oral (verbal) expression of language stabilized.
Home health care: percentage of patients with a decrease in the current number of (observable) surgical wounds.
Home health care: percentage of patients with improvement in ability to do laundry.
Home health care: percentage of patients with improvement in ability to shop.
Home health care: percentage of patients with improvement in anxiety frequency.
Home health care: percentage of patients with improvement in behavioral problem frequency.
Home health care: percentage of patients with improvement in bowel incontinence frequency.
Home health care: percentage of patients with improvement in cognitive functioning.
Home health care: percentage of patients with improvement in dressing lower body.
Home health care: percentage of patients with improvement in dressing upper body.
Home health care: percentage of patients with improvement in dyspnea.
Home health care: percentage of patients with improvement in eating.
Home health care: percentage of patients with improvement in grooming.
Home health care: percentage of patients with improvement in housekeeping.
Home health care: percentage of patients with improvement in light meal preparation.
Home health care: percentage of patients with improvement in status of surgical wounds.
Home health care: percentage of patients with improvement in telephone use.
Home health care: percentage of patients with improvement in urinary incontinence.
Home health care: percentage of patients with improvement in urinary tract infection.
Home health care: percentage of patients with stabilization in ability to do laundry.
Home health care: percentage of patients with stabilization in ability to shop.
Home health care: percentage of patients with stabilization in anxiety frequency.
Home health care: percentage of patients with stabilization in cognitive functioning.
Home health care: percentage of patients with stabilization in grooming.
Home health care: percentage of patients with stabilization in housekeeping.
Home health care: percentage of patients with stabilization in light meal preparation.
Home health care: percentage of patients with stabilization in management of oral medications.
Home health care: percentage of patients with stabilization in telephone use.
Home health care: percentage of patients with stabilization in transferring.
Hospital inpatients' experiences: adult inpatients' ratings of this hospital.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often the area around their room was quiet at night.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff communicated well about medications.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff was responsive to their needs.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their doctors communicated well.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their nurses communicated well.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their pain was controlled.
Hospital inpatients' experiences: percentage of adult inpatients who reported how often their room and bathroom were kept clean.
Hospital inpatients' experiences: percentage of adult inpatients who reported whether they were provided specific discharge information.
Hospital inpatients' experiences: percentage of adult inpatients who reported whether they would recommend this hospital to their friends and family.
Hospital outpatient surgery: percentage of surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
Hospital outpatient surgery: percentage of surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision.
In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often their nephrologist cared and communicated well.
In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often they were satisfied with the quality of dialysis center care and operations.
In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported whether specified information was provided to them.
In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center staff.
In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center.
In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their kidney doctors.
Nursing facility chronic care: percent of eligible and willing long-stay residents given the influenza vaccination during the flu season.
Nursing facility chronic care: percent of eligible and willing long-stay residents who were assessed and given pneumococcal vaccination.
Nursing facility chronic care: percent of high-risk residents who have pressure sores.
Nursing facility chronic care: percent of low-risk residents who have pressure sores.
Nursing facility chronic care: percent of low-risk residents who lose control of their bowels or bladder.
Nursing facility chronic care: percent of residents who have become more depressed or anxious.
Nursing facility chronic care: percent of residents who have moderate to severe pain.
Nursing facility chronic care: percent of residents who have/had a catheter inserted and left in their bladder.
Nursing facility chronic care: percent of residents who lose too much weight.
Nursing facility chronic care: percent of residents who spent most of their time in bed or in a chair during the assessment period.
Nursing facility chronic care: percent of residents who were physically restrained.
Nursing facility chronic care: percent of residents whose ability to move about in and around their room got worse.
Nursing facility chronic care: percent of residents whose need for help with daily activities has increased.
Nursing facility chronic care: percent of residents with a urinary tract infection.
Nursing facility post acute care: percent of eligible and willing short-stay residents given the influenza vaccination during the flu season.
Nursing facility post acute care: percent of eligible and willing short-stay residents who were assessed and given pneumococcal vaccination.
Nursing facility post-acute care: percent of short-stay residents who had moderate to severe pain.
Nursing facility post-acute care: percent of short-stay residents who have pressure sores.
Nursing facility post-acute care: percent of short-stay residents with delirium.
Pneumonia (PN): 30-day mortality rate.
Pneumonia: median time from arrival at the hospital to the administration of the first dose of antibiotic at the hospital. [NQMC Update Pending]
Pneumonia: percent of immunocompetent intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. [NQMC Update Pending]
Pneumonia: percent of immunocompetent non-intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. [NQMC Update Pending]
Pneumonia: percent of immunocompetent patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. [NQMC Update Pending]
Pneumonia: percent of patients age 50 years and older, hospitalized during October, November, December, January, February, or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. [NQMC Update Pending]
Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. [NQMC Update Pending]
Pneumonia: percent of patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital. [NQMC Update Pending]
Pneumonia: percent of patients who were transferred or admitted to the intensive care unit (ICU) within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival. [NQMC Update Pending]
Pneumonia: percent of patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics. [NQMC Update Pending]
Pneumonia: percent of patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]
Pneumonia: thirty-day all-cause risk standardized readmission rate following pneumonia hospitalization.
Pregnancy and related conditions: percent of live-born neonates who expire before the neonate becomes age 28 days.
Pregnancy and related conditions: percent of patients who have vaginal deliveries with third or fourth degree perineal laceration.
Pregnancy and related conditions: percent of patients with vaginal birth after cesarean section (VBAC).
Stroke: percent of acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at the hospital within 3 hours (less than or equal to 180 minutes) of time last known well.
Stroke: percent of ischemic and hemorrhagic stroke patients who have received venous thromboembolism (VTE) prophylaxis or who have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.
Stroke: percent of ischemic or hemorrhage stroke patients who were assessed for rehabilitation services.
Stroke: percent of ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during their hospital stay addressing all five specified education categories.
Stroke: percent of ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.
Stroke: percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.
Stroke: percent of ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.
Stroke: percent of ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival, who are prescribed a statin medication at hospital discharge.
Surgical care improvement project: percent of cardiac surgery patients with controlled 6 A.M. postoperative blood glucose. [NQMC Update Pending]
Surgical care improvement project: percent of patients who received prophylactic antibiotics consistent with current guidelines. [NQMC Update Pending]
Surgical care improvement project: percent of patients who received prophylactic antibiotics within one hour prior to surgical incision. [NQMC Update Pending]
Surgical care improvement project: percent of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. [NQMC Update Pending]
Surgical care improvement project: percent of surgery patients on beta-blocker therapy prior to admission who received a beta-blocker during the perioperative period. [NQMC Update Pending]
Surgical care improvement project: percent of surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery. [NQMC Update Pending]
Surgical care improvement project: percent of surgery patients with appropriate hair removal. [NQMC Update Pending]
Surgical care improvement project: percent of surgery patients with recommended VTE prophylaxis ordered anytime from hospital arrival to 48 hours after Surgery End Time. [NQMC Update Pending]
Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE during hospitalization (not present on arrival) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnosis testing order date.
Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE that are discharged to home, to home with home health or home hospice, or discharged/transferred to court/law enforcement on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions.
Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous or subcutaneous) anticoagulation and warfarin therapy.
Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE who received intravenous unfractionated heparin therapy doses AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.
Venous thromboembolism (VTE): percent of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.
Venous thromboembolism (VTE): percent of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or day after initial admission (or transfer) to the intensive care unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).
Centers for Medicare & Medicaid Services/The Joint Commission(50)
Acute myocardial infarction (AMI): 30-day mortality rate.
Acute myocardial infarction (AMI): thirty-day all-cause risk standardized readmission rate following AMI hospitalization.
Acute myocardial infarction: median time from hospital arrival to administration of fibrinolytic agent in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]
Acute myocardial infarction: median time from hospital arrival to primary PCI in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. [NQMC Update Pending]
Acute myocardial infarction: percent of patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less. [NQMC Update Pending]
Acute myocardial infarction: percent of patients receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. [NQMC Update Pending]
Acute myocardial infarction: percent of patients with a history of smoking cigarettes who receive smoking cessation advice or counseling during the hospital stay. [NQMC Update Pending]
Acute myocardial infarction: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]
Acute myocardial infarction: percent of patients without aspirin contraindications who are prescribed aspirin at hospital discharge. [NQMC Update Pending]
Acute myocardial infarction: percent of patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. [NQMC Update Pending]
Acute myocardial infarction: percent of patients without beta-blocker contraindications who are prescribed a beta-blocker at hospital discharge. [NQMC Update Pending]
Children's asthma care: percent of pediatric asthma inpatients who received relievers during hospitalization.
Children's asthma care: percent of pediatric asthma inpatients who received systemic corticosteroids during hospitalization.
Children's asthma care: percent of pediatric asthma inpatients with documentation that they or their caregivers were given a written Home Management Plan of Care (HMPC) document.
Heart failure (HF): 30-day mortality rate.
Heart failure (HF): thirty-day all-cause risk standardized readmission rate following HF hospitalization.
Heart failure: percent of patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. [NQMC Update Pending]
Heart failure: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]
Heart failure: percent of patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. [NQMC Update Pending]
Heart failure: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. [NQMC Update Pending]
Pneumonia (PN): 30-day mortality rate.
Pneumonia: percent of patients age 50 years and older, hospitalized during October, November, December, January, February, or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. [NQMC Update Pending]
Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. [NQMC Update Pending]
Pneumonia: percent of patients who receive their first dose of antibiotics within 6 hours after arrival at the hospital. [NQMC Update Pending]
Pneumonia: percent of patients who were transferred or admitted to the intensive care unit (ICU) within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival. [NQMC Update Pending]
Pneumonia: percent of patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics. [NQMC Update Pending]
Pneumonia: percent of patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. [NQMC Update Pending]
Pneumonia: thirty-day all-cause risk standardized readmission rate following pneumonia hospitalization.
Stroke: percent of acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at the hospital within 3 hours (less than or equal to 180 minutes) of time last known well.
Stroke: percent of ischemic and hemorrhagic stroke patients who have received venous thromboembolism (VTE) prophylaxis or who have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.
Stroke: percent of ischemic or hemorrhage stroke patients who were assessed for rehabilitation services.
Stroke: percent of ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during their hospital stay addressing all five specified education categories.
Stroke: percent of ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.
Stroke: percent of ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.
Stroke: percent of ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.
Stroke: percent of ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival, who are prescribed a statin medication at hospital discharge.
Surgical care improvement project: percent of cardiac surgery patients with controlled 6 A.M. postoperative blood glucose. [NQMC Update Pending]
Surgical care improvement project: percent of patients who received prophylactic antibiotics consistent with current guidelines. [NQMC Update Pending]
Surgical care improvement project: percent of patients who received prophylactic antibiotics within one hour prior to surgical incision. [NQMC Update Pending]
Surgical care improvement project: percent of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. [NQMC Update Pending]
Surgical care improvement project: percent of surgery patients on beta-blocker therapy prior to admission who received a beta-blocker during the perioperative period. [NQMC Update Pending]
Surgical care improvement project: percent of surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery. [NQMC Update Pending]
Surgical care improvement project: percent of surgery patients with appropriate hair removal. [NQMC Update Pending]
Surgical care improvement project: percent of surgery patients with recommended VTE prophylaxis ordered anytime from hospital arrival to 48 hours after Surgery End Time. [NQMC Update Pending]
Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE during hospitalization (not present on arrival) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnosis testing order date.
Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE that are discharged to home, to home with home health or home hospice, or discharged/transferred to court/law enforcement on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions.
Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous or subcutaneous) anticoagulation and warfarin therapy.
Venous thromboembolism (VTE): percent of patients diagnosed with confirmed VTE who received intravenous unfractionated heparin therapy doses AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.
Venous thromboembolism (VTE): percent of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.
Venous thromboembolism (VTE): percent of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or day after initial admission (or transfer) to the intensive care unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).
Child and Adolescent Health Measurement Initiative(37)
Anticipatory guidance and parental education (AGPE) about development and behavior of the child from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met.
Anticipatory guidance and parental education (AGPE) about injury prevention from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met.
Anticipatory guidance and parental education (AGPE) about the physical care of the child from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met.
Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): average percentage of recommended topics discussed by a child's doctor(s) or other health provider(s).
Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): average percentage of topics for which parents had their informational needs met.
Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): proportion of children whose health care provider(s) discussed at least 80% of the recommended AGPE topics.
Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met on all recommended anticipatory guidance and parental education topics assessed.
Ask about parental concerns (developmental surveillance): proportion of children whose parents were asked by their child's health care provider if they have concerns about their child's learning, development and behavior.
Assessment of psychosocial well-being of parent(s) in the family: average percentage of recommended topics assessed.
Assessment of psychosocial well-being of parent(s) in the family: proportion of children whose parents were assessed for one or more topics related to psychosocial well-being.
Assessment of smoking, substance abuse, safety, and firearms risks in the family by a child's doctor(s) or other health care provider(s): proportion of children whose parents were assessed for one or more risk factors.
Assessment of smoking, substance abuse, safety, and firearms risks in the family: average percentage of recommended topics assessed.
Care coordination (CC): proportion of children needing more than one health care service who received coordinated care.
Communication and experience of care: mean score on seven items asking about helpfulness of office staff, overall rating of care and whether doctor/other providers listen carefully, explain things clearly, respect you, spend enough time.
Effect of care provided on parental confidence: proportion of children whose parents reported care had a positive influence on their confidence in parenting their child and managing their responsibilities.
Family-centered care (FCC): average percentage of recommended aspects of family-centered care regularly received.
Family-centered care (FCC): proportion of children whose parents routinely received all aspects of family-centered care.
Follow-up for children at risk for delays: proportion of children who were determined to be at significant risk for developmental, behavioral, or social delays who received some level of follow-up health care.
Health information: proportion of children whose parents received all health information.
Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get prescription medicines for their enrolled children with chronic conditions through their health plan.
Health plan members' experiences: percentage of parents or guardians who reported how often it was easy to get specialized services for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported their experiences with getting needed information about their children's care for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported their experiences with shared decision-making for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported their experiences with their children's personal doctor or nurse for their enrolled children with chronic conditions.
Health plan members' experiences: percentage of parents or guardians who reported they received assistance with coordination of care and services for their enrolled children with chronic conditions.
Helpfulness of care provided to parents: proportion of children whose parents reported care provided was helpful or very helpful on core aspects of preventive and developmental health care.
Helpfulness of counseling: mean score on six items asking about the helpfulness of counseling among young adults who received counseling on selected topics.
Information about resources for parents in the community: proportion of parents who had their informational needs met.
Information to address parental concerns: proportion of children whose parents had concerns about their child's learning, development and behavior and they received information to address their concerns.
Preventive and developmental health care for young children: average percentage of individual care components (assessed in the Promoting Healthy Development Survey [PHDS]) a child received.
Preventive and developmental health care for young children: proportion of children who received all individual care components measures in the Promoting Healthy Development Survey (PHDS).
Preventive screening and counseling on emotional health and relationship issues: average proportion saying "yes" to six items about whether provider(s) discussed/screened for feeling sad or depressed, school performance, friends, suicide and sexual orientation.
Preventive screening and counseling on risky behaviors: average proportion saying "yes" to ten items about whether provider(s) discussed/screened on smoking, alcohol use, helmet use, drunk driving, chewing tobacco, street drugs, steroid pills, sexual/physical abuse, violence, guns.
Preventive screening and counseling on sexual activity and sexually transmitted diseases (STDs): average proportion saying "yes" to four items about whether provider(s) discussed/screened on birth control, condoms and prevention of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and STDs.
Preventive screening and counseling on weight, healthy diet and exercise: average proportion saying "yes" to three items.
Private and confidential care: average proportion reporting that they had a private and/or confidential visit.
Standardized developmental and behavioral screening: proportion of children whose health care provider administered a parent-completed standardized developmental and behavioral screening tool.
Chinman, Matthew, Ph.D. (MIRECC); Young, Alexander S., M.D., M.S.H.S. (MIRECC); Sandy Forquer (Comprehensive Neuroscience Inc.); Edward Knight (ValueOptions); Anita Miller (ValueOptions); Melissa Rowe (RAND)(15)
Competency Assessment Instrument (CAI): provider's mean score on the "Client Preferences" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Community Resources" scale.
Competency Assessment Instrument (CAI): Provider's mean score on the "Evidence-based Practice" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Family Education" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Family Involvement" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Goals" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Holistic Approach" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Intensive Case Management" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Medication Management" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Natural Supports" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Rehabilitation" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Skill Advocacy" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Stigma" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Stress" scale.
Competency Assessment Instrument (CAI): Provider's mean score on the "Team Value" scale.
Chinman, Matthew, Ph.D.; Young, Alexander S., M.D., M.S.H.S.; Veterans Administration Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC)(15)
Competency Assessment Instrument (CAI): provider's mean score on the "Client Preferences" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Community Resources" scale.
Competency Assessment Instrument (CAI): Provider's mean score on the "Evidence-based Practice" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Family Education" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Family Involvement" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Goals" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Holistic Approach" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Intensive Case Management" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Medication Management" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Natural Supports" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Rehabilitation" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Skill Advocacy" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Stigma" scale.
Competency Assessment Instrument (CAI): provider's mean score on the "Stress" scale.
Competency Assessment Instrument (CAI): Provider's mean score on the "Team Value" scale.
College of American Pathologists(2)
Pathology: percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.
Pathology: percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.
Eisen, Susan V. PhD(7)
Mental health/substance abuse: mean of patient's change scores on the "Interpersonal Relationships" subscale of the BASIS-24® survey.
Mental health/substance abuse: mean of patients' change scores on the "Depression/Functioning" subscale of the BASIS-24® survey.
Mental health/substance abuse: mean of patients' change scores on the "Emotional Lability" subscale of the BASIS-24® survey.
Mental health/substance abuse: mean of patients' change scores on the "Psychosis" subscale of the BASIS-24® survey.
Mental health/substance abuse: mean of patients' change scores on the "Self-harm" subscale of the BASIS-24® survey.
Mental health/substance abuse: mean of patients' change scores on the "Substance Abuse" subscale of the BASIS-24® survey.
Mental health/substance abuse: mean of patients' overall change scores on the BASIS-24® survey.
Family Violence Prevention Fund(8)
Domestic violence: percent of adult and adolescent patients assessed who disclosed that they were victims of abuse.
Domestic violence: percent of adult and adolescent patients seen by a provider who were assessed for intimate partner violence (IPV) during the last year.
Domestic violence: percent of adult and adolescent patients who screened negative for current or past intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV who were offered information about IPV and referrals.
Domestic violence: percent of adult and adolescent patients who screened negative for current or past intimate partner violence (IPV) but whom the provider is still concerned may be a victim of IPV whose records include prompts for specific follow-up questions about IPV to occur at the patient's next visit.
Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) and who answered yes to initial danger assessment questions for whom records indicate that a suicide and homicide assessment was conducted.
Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) for whom records indicate that specified assessments were conducted.
Domestic violence: percent of adult and adolescent patients who screened positive for current or past intimate partner violence (IPV) for whom records indicate that specified intervention and treatment plans were offered.
Domestic violence: percent of providers of health care services to adult and adolescent patients in the clinical setting who documented that they complied with assessment protocols.
Focus On Therapeutic Outcomes, Inc.(6)
Foot/ankle functional status: mean change score in foot/ankle functional status of patients with foot/ankle impairments receiving physical rehabilitation.
Hip functional status: mean change score in hip functional status of patients with hip impairments receiving physical rehabilitation.
Knee functional status: mean change score in knee functional status of patients with knee impairments receiving physical rehabilitation.
Lumbar functional status: mean change score in lumbar functional status for patients with lumbar impairments receiving physical rehabilitation.
Physical functional health status: mean change score in physical functional health status of patients receiving physical rehabilitation.
Shoulder functional status: mean change score in shoulder functional status with shoulder impairments receiving physical rehabilitation.
Grupo de Investigación sobre Gestión de la Calidad en Servicios de Salud, University of Murcia, under contract to the Spanish Ministry of Health(72)
Appropriate environmental conditions in medication preparation and dispensing areas: does the hospital have clean, well-organized, quiet and well-lit medication preparation and dispensing areas?
Assessment and prevention of thrombotic and ischemic complications in patients undergoing procedures with pneumatic tourniquet: does the hospital have guidelines or protocol for nursing practices for controlled ischemia in surgical procedures and post-operative care?
Assessment and prevention of thrombotic and ischemic complications in patients undergoing procedures with pneumatic tourniquet: percentage of failures in monitoring ischemia time and pressure in surgical procedures using pneumatic tourniquet.
Assessment and prevention of thrombotic and ischemic complications in patients undergoing procedures with pneumatic tourniquet: percentage of surgical procedures in which pneumatic tourniquet pressure and time of inflation are recorded.
Assessment of risk and prevention of malnutrition: does the hospital have guidelines or protocol for prevention of malnutrition?
Assessment of risk and prevention of malnutrition: percentage of intensive care unit (ICU) patients receiving artificial nutrition whose calorific-protein requirement is calculated on a regular basis.
Assessment of risk and prevention of malnutrition: percentage of intensive care unit (ICU) patients who are assessed for risk of malnutrition within 24 hours after admission.
Availability of pharmacist: does the hospital have pharmacists available 24 hours a day?
Chemotherapy orders: percentage of healthcare professionals who affirm that in their unit or area orders relating to chemotherapy are never given verbally.
Communication of changes in patient care: percentage of healthcare professionals who affirm that in their unit or area information affecting a patient diagnosis is always communicated clearly and rapidly to all professionals involved in the care of that patient.
Communication of changes in patient care: percentage of healthcare professionals who affirm that in their unit or area new prescriptions are always ordered revising all the medication being taken by the patient.
Communication of changes in patient care: percentage of healthcare providers who affirm that in their unit or area changes in patients medications are always communicated clearly and rapidly to all professionals involved in the care of those patients.
End-of-life care: does the hospital have rules or protocols on terminal patients' preferences and advance directives?
End-of-life care: percentage of healthcare professionals who affirm that in their unit or area enquiries are always made about terminal patients' preferences regarding life-support procedures and treatment.
Hand washing: does the hospital have a protocol for hand washing by healthcare providers?
Hand washing: does the hospital have appropriate infrastructure for hand washing in all units of the hospital in which patient care is administered?
Hand washing: does the hospital have training courses in hand washing within the last year's training activities?
Hand washing: percentage of failures in compliance with standard norms on hand washing.
Identification of high-alert medications: does the hospital have a list of high-alert medications?
Identification of high-alert medications: does the hospital have norms approved by the hospital on administration on high-alert medications?
Identification of high-alert medications: does the hospital have norms on special labeling and storage of high-alert medications?
Identification of high-alert medications: does the hospital have pre-printed prescriptions for Cytostatics drugs?
Influenza vaccination for all hospital workers: percentage of healthcare workers vaccinated against influenza.
Influenza vaccination for hospital personnel: does the hospital have guidelines or protocol on influenza vaccination for staff?
Informed consent: percentage of healthcare professionals who affirm that in their unit or area steps are always taken to ensure that patients have understood the risks and complications before they sign the informed consent form.
Management of anticoagulants: does the hospital have a guideline or protocol for the management of oral anticoagulants by patients, for patients who receive anticoagulants from outpatient clinics or health centers?
Management of anticoagulants: does the hospital have norms for heparin administration using a nomogram?
Management of anticoagulants: percentage of patients assessed for weight and renal function before starting anticoagulant therapy with heparin.
Medication errors: average number of non-recommended abbreviations, symbols or dose designations used in medical prescription.
Medication errors: does the hospital have a list, rules or guidelines on abbreviations, symbols and dose designations connected with medication errors?
Medication errors: does the hospital have a protocol for detection, recording and reporting of medication errors that involves the pharmacy service?
Medication errors: percentage of medical prescriptions free of non-recommended abbreviations, symbols or dose designations.
Nurse staff workload: does the hospital assess nursing staff workload?
Nurse staffing levels: does the hospital have specific rules on nurse staffing levels?
Preparation of summaries and reports: percentage of healthcare professionals who affirm that in their unit or area clinical reports and summaries are never written without having all the necessary data within sight.
Prevention of central venous catheter (CVC)-related infections: does the hospital have guidelines or protocol for prevention of CVC-related infections?
Prevention of central venous catheter (CVC)-related infections: percentage of CVCs in use that are correctly maintained (adequate care).
Prevention of central venous catheter (CVC)-related infections: percentage of full barrier precautions items not performed when inserting CVCs.
Prevention of central venous catheter (CVC)-related infections: percentage of maintenance failures in CVCs.
Prevention of contrast-induced renal damage: does the hospital have guidelines or protocol approved by the hospital for prevention of acute nephropathy caused by exposure to iodine-containing contrast media?
Prevention of contrast-induced renal damage: percentage of patients at risk of developing acute nephropathy to whom a prevention program is applied prior to tests with iodine-containing contrast media.
Prevention of contrast-induced renal damage: percentage of patients whose renal function (creatinine level) is assessed within the 24 hours prior to undergoing tests with iodine-containing contrast media.
Prevention of pressure ulcers: does the hospital have rules or protocols for prevention of pressure ulcers?
Prevention of pressure ulcers: percentage of days at risk of patients over 64 years of age with appropriate postural changes according to their risk of developing pressure ulcers.
Prevention of pressure ulcers: percentage of patients 65 years of age or older who were assessed within 24 hours of admission to hospital for the risk of developing pressure ulcers.
Prevention of surgical wound infection: does the hospital have guidelines or protocol approved by the hospital for antibiotic prophylaxis in surgery?
Prevention of surgical wound infection: does the hospital have guidelines or protocol approved by the hospital for specific nursing practices for post-operative wound care?
Prevention of surgical wound infection: does the hospital have guidelines or protocol for nursing practices for surgical preparation of skin and mucous?
Prevention of surgical wound infection: does the hospital take steps to monitor and control normothermia in major surgery (procedures lasting more than two hours).
Prevention of surgical wound infection: percentage of patients who receive an inspired oxygen fraction greater than or equal to 80% in major surgery (procedures lasting more than two hours) with general anesthesia.
Prevention of surgical wound infection: percentage of surgical procedures that meet recommendations on antibiotic prophylaxis.
Prevention of surgical wound infections: percentage of errors (quality defects) in antibiotic prophylaxis for surgical procedures.
Prevention of venous thromboembolism (VTE): does the hospital have guidelines or protocol for prevention of VTE?
Prevention of venous thromboembolism (VTE): percentage of patients over 64 years of age assessed in the first 24 hours after admission to hospital for the risk of developing VTE.
Prevention of wrong-site or wrong-patient surgery: does the hospital have a protocol for prevention of wrong-site or wrong-patient surgery?
Radiograph labeling: does the hospital have a protocol for prevention of erroneous labeling of radiographs?
Radiograph labeling: percentage of errors in identification of simple radiographs.
Radiograph labeling: percentage of simple radiographs that are correctly identified.
Standardized methods for labeling, packaging and storing medications: does the hospital have guidelines or protocol approved by the hospital on maintenance of cardiac arrest carts?
Standardized methods for labeling, packaging and storing medications: does the hospital have guidelines or protocols on correct storage, conservation and restocking of medications in nurse station dispensaries?
Standardized methods for labeling, packaging and storing medications: does the hospital have guidelines or protocols on correct storage, conservation, and restocking of medications in pharmacy service?
Standardized methods for labeling, packaging and storing medications: does the hospital have guidelines or protocols on labeling and repackaging of medications in unit doses?
Standardized methods for labeling, packaging and storing medications: does the hospital pharmacy service have a list of antidotes including indication of location, minimum stocks and use-by date control system?
Standardized methods for labeling, packaging and storing medications: percentage of failures in conservation and storage of medications in the hospital pharmacy.
Standardized methods for labeling, packaging and storing medications: percentage of failures in labeling of medications prepared in hospital pharmacy service.
Standardized methods for labeling, packaging and storing medications: percentage of failures in labeling, conservation and storage of medications in wards, emergency department and operating room dispensaries.
Standardized methods for labeling, packaging and storing medications: percentage of failures in maintenance of medication and equipment available on cardiac arrest carts.
Unit-dose dispensation: percentage of hospital beds with unit-dose dispensation.
Validation of medication orders: percentage of prescriptions validated by pharmacy service before dispensation.
Verbal orders: does the hospital have rules or a protocol on how to deal with verbal orders?
Verbal orders: percentage of healthcare professionals who affirm that in their unit or area orders received verbally are always written down.
Verbal orders: percentage of healthcare professionals who affirm that in their unit or area verbal orders are always repeated-back out loud.
Harvard Medical School(17)
Behavioral health care patients' experiences: percentage of adult patients who rated how much improvement they perceived in themselves.
Behavioral health care patients' experiences: percentage of adult patients who reported how much of a problem they had getting treatment and information from their health plan or managed behavior health organization.
Behavioral health care patients' experiences: percentage of adult patients who reported how much they were helped by the counseling or treatment they received.
Behavioral health care patients' experiences: percentage of adult patients who reported how often their clinicians communicated well.
Behavioral health care patients' experiences: percentage of adult patients who reported how often they get treatment quickly.
Behavioral health care patients' experiences: percentage of adult patients who reported how often they were seen within 15 minutes of their appointment.
Behavioral health care patients' experiences: percentage of adult patients who reported whether anyone shared information regarding their counseling or treatment that should have been kept private.
Behavioral health care patients' experiences: percentage of adult patients who reported whether someone talked to them about including family or friends in their counseling or treatment.
Behavioral health care patients' experiences: percentage of adult patients who reported whether the care they received was responsive to their cultural needs.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they felt they could refuse a specific type of medicine or treatment.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given enough information to manage their condition.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were given information about patient rights.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were provided information about treatment options.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about medication side effects.
Behavioral health care patients' experiences: percentage of adult patients who reported whether they were told about other ways to receive treatment after their benefits were used up.
Behavioral health care patients' satisfaction: adult patients' overall rating of the counseling or treatment they received.
Behavioral health care patients' satisfaction: adult patients' overall rating of their health plan for counseling or treatment.
Health Resources and Services Administration(42)
Asthma: average number of lost workdays and/or school days in the past 30 days.
Asthma: average number of symptom-free days in the previous two weeks.
Asthma: percent of patients evaluated for environmental triggers other than environmental tobacco smoke (dust mites, cats, dogs, molds/fungi, cockroaches) either by history of exposure and/or by allergy testing.
Asthma: percent of patients older than 5 years with moderate or severe persistent asthma who have established a "personal best" peak flow.
Asthma: percent of patients who have a record of influenza immunization in the past 12 months.
Asthma: percent of patients who have had a visit to an Emergency Department (ED)/Urgent Care office for asthma in the past six months.
Asthma: percent of patients with a documented screening for depression in the past 12 months.
Asthma: percent of patients with a reported exposure to environmental tobacco smoke at last visit.
Asthma: percent of patients with a severity assessment at last contact (visit or phone).
Asthma: percent of patients with documented self-management goals in the last 12 months.
Asthma: percent of patients with persistent asthma at last contact who are on an anti-inflammatory medication.
Depression: percent of clinically significant depression patients who attain a 5 point or greater reduction in Patient Health Questionnaire (PHQ) score within 6 months after their New Episode PHQ.
Depression: percent of clinically significant depression patients who have a documented Current Patient Health Questionnaire (PHQ) reassessment between 4 to 8 weeks after their last New Episode PHQ.
Depression: percent of clinically significant depression patients who have had a documented follow-up 1 to 3 weeks after their last New Episode Patient Health Questionnaire (PHQ).
Depression: percent of clinically significant depression patients who, within one month of last New Episode Patient Health Questionnaire (PHQ), are on an antidepressant and/or in psychotherapy.
Depression: percent of clinically significant depression patients with a 50 percent or greater reduction in Patient Health Questionnaire (PHQ) 4 months or longer after the last New Episode PHQ.
Depression: percent of clinically significant depression patients with a 50 percent or greater reduction in Patient Health Questionnaire (PHQ).
Depression: percent of clinically significant depression patients with a Patient Health Questionnaire (PHQ) score less than 5, 4 months or longer after their last New Episode PHQ.
Depression: percent of patients with a diagnoses of minor depression, depression not otherwise specified (NOS), or adjustment disorder (New Episode Patient Health Questionnaire [PHQ] less than 10) who are NOT on an antidepressant.
Depression: percent of patients with a diagnosis of depression and a documented Patient Health Questionnaire (PHQ) score within the last 6 months.
Depression: percent of patients with a diagnosis of depression reporting an improvement in function.
Depression: percent of patients with a diagnosis of depression with documented self-management goals set within the last 12 months.
Depression: percent of patients with a diagnosis of major depression or dysthymia who, as of their last visit, are taking an antidepressant.
Depression: percent of patients with diagnosis of major depression or dysthymia who have been on antidepressants for at least 6 months.
Diabetes mellitus: average HbA1c value for diabetic patients in the clinical information system.
Diabetes mellitus: percent of patients 12 to 70 years of age who are not already on angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) and have had a microalbuminuria screening test in the last 12 months.
Diabetes mellitus: percent of patients 40 years and older who have a current prescription for aspirin or other antithrombotic agent.
Diabetes mellitus: percent of patients 40 years and older who have a current prescription for statins.
Diabetes mellitus: percent of patients 55 years and older who have a current prescription for angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) medication.
Diabetes mellitus: percent of patients who are current smokers (documented in the last 12 months).
Diabetes mellitus: percent of patients who have had a comprehensive foot exam in the past 12 months.
Diabetes mellitus: percent of patients who have had a dilated eye exam in last 12 months.
Diabetes mellitus: percent of patients who have had one pneumococcal vaccination at any time.
Diabetes mellitus: percent of patients who obtained a dental exam in the last 12 months.
Diabetes mellitus: percent of patients who obtained an influenza vaccination in the last 12 months.
Diabetes mellitus: percent of patients whose last documented exercise rate (within the last 12 months) was three times per week for at least 20 minutes.
Diabetes mellitus: percent of patients whose most recent fasting low-density lipoprotein (LDL) was less than 100 (in the last 12 months).
Diabetes mellitus: percent of patients with 2 HbA1c's in the last year (at least 3 months apart).
Diabetes mellitus: percent of patients with a body mass index (BMI) greater than 25 who have lost 10 pounds at any time in the last 12 months.
Diabetes mellitus: percent of patients with a documented screening for depression in the past 12 months.
Diabetes mellitus: percent of patients with blood pressure reading less than 130/80 in the last 12 months.
Diabetes mellitus: percent of patients with documented self-management goals in the last 12 months.
HealthPartners(4)
Cervical cancer screening: percentage of women ages 21 years and older in the measurement year screened in accordance with evidence-based standards. [NQMC Update Pending]
Depression: percentage of members ages 18 years and older diagnosed with a new episode of depression, treated with antidepressant medication and optimally managed. [NQMC Update Pending]
Preventive services: percentage of adult enrolled members ages 19 years and older that are up-to-date for all appropriate preventive services. [NQMC Update Pending]
Preventive services: percentage of enrolled members ages less than or equal to 18 years who are up-to-date for all appropriate preventive services. [NQMC Update Pending]
HRSA Health Disparities Collaboratives: Asthma Collaborative(11)
Asthma: average number of lost workdays and/or school days in the past 30 days.
Asthma: average number of symptom-free days in the previous two weeks.
Asthma: percent of patients evaluated for environmental triggers other than environmental tobacco smoke (dust mites, cats, dogs, molds/fungi, cockroaches) either by history of exposure and/or by allergy testing.
Asthma: percent of patients older than 5 years with moderate or severe persistent asthma who have established a "personal best" peak flow.
Asthma: percent of patients who have a record of influenza immunization in the past 12 months.
Asthma: percent of patients who have had a visit to an Emergency Department (ED)/Urgent Care office for asthma in the past six months.
Asthma: percent of patients with a documented screening for depression in the past 12 months.
Asthma: percent of patients with a reported exposure to environmental tobacco smoke at last visit.
Asthma: percent of patients with a severity assessment at last contact (visit or phone).
Asthma: percent of patients with documented self-management goals in the last 12 months.
Asthma: percent of patients with persistent asthma at last contact who are on an anti-inflammatory medication.
HRSA Health Disparities Collaboratives: Depression Collaborative(13)
Depression: percent of clinically significant depression patients who attain a 5 point or greater reduction in Patient Health Questionnaire (PHQ) score within 6 months after their New Episode PHQ.
Depression: percent of clinically significant depression patients who have a documented Current Patient Health Questionnaire (PHQ) reassessment between 4 to 8 weeks after their last New Episode PHQ.
Depression: percent of clinically significant depression patients who have had a documented follow-up 1 to 3 weeks after their last New Episode Patient Health Questionnaire (PHQ).
Depression: percent of clinically significant depression patients who, within one month of last New Episode Patient Health Questionnaire (PHQ), are on an antidepressant and/or in psychotherapy.
Depression: percent of clinically significant depression patients with a 50 percent or greater reduction in Patient Health Questionnaire (PHQ) 4 months or longer after the last New Episode PHQ.
Depression: percent of clinically significant depression patients with a 50 percent or greater reduction in Patient Health Questionnaire (PHQ).
Depression: percent of clinically significant depression patients with a Patient Health Questionnaire (PHQ) score less than 5, 4 months or longer after their last New Episode PHQ.
Depression: percent of patients with a diagnoses of minor depression, depression not otherwise specified (NOS), or adjustment disorder (New Episode Patient Health Questionnaire [PHQ] less than 10) who are NOT on an antidepressant.
Depression: percent of patients with a diagnosis of depression and a documented Patient Health Questionnaire (PHQ) score within the last 6 months.
Depression: percent of patients with a diagnosis of depression reporting an improvement in function.
Depression: percent of patients with a diagnosis of depression with documented self-management goals set within the last 12 months.
Depression: percent of patients with a diagnosis of major depression or dysthymia who, as of their last visit, are taking an antidepressant.
Depression: percent of patients with diagnosis of major depression or dysthymia who have been on antidepressants for at least 6 months.
HRSA Health Disparities Collaboratives: Diabetes Collaborative(18)
Diabetes mellitus: average HbA1c value for diabetic patients in the clinical information system.
Diabetes mellitus: percent of patients 12 to 70 years of age who are not already on angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) and have had a microalbuminuria screening test in the last 12 months.
Diabetes mellitus: percent of patients 40 years and older who have a current prescription for aspirin or other antithrombotic agent.
Diabetes mellitus: percent of patients 40 years and older who have a current prescription for statins.
Diabetes mellitus: percent of patients 55 years and older who have a current prescription for angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) medication.
Diabetes mellitus: percent of patients who are current smokers (documented in the last 12 months).
Diabetes mellitus: percent of patients who have had a comprehensive foot exam in the past 12 months.
Diabetes mellitus: percent of patients who have had a dilated eye exam in last 12 months.
Diabetes mellitus: percent of patients who have had one pneumococcal vaccination at any time.
Diabetes mellitus: percent of patients who obtained a dental exam in the last 12 months.
Diabetes mellitus: percent of patients who obtained an influenza vaccination in the last 12 months.
Diabetes mellitus: percent of patients whose last documented exercise rate (within the last 12 months) was three times per week for at least 20 minutes.
Diabetes mellitus: percent of patients whose most recent fasting low-density lipoprotein (LDL) was less than 100 (in the last 12 months).
Diabetes mellitus: percent of patients with 2 HbA1c's in the last year (at least 3 months apart).
Diabetes mellitus: percent of patients with a body mass index (BMI) greater than 25 who have lost 10 pounds at any time in the last 12 months.
Diabetes mellitus: percent of patients with a documented screening for depression in the past 12 months.
Diabetes mellitus: percent of patients with blood pressure reading less than 130/80 in the last 12 months.
Diabetes mellitus: percent of patients with documented self-management goals in the last 12 months.
Inouye, Sharon K. M.D., M.P.H.(1)
Delirium: proportion of patients meeting diagnostic criteria on the Confusion Assessment Method (CAM).
Institute for Clinical Systems Improvement(81)
Acute care prevention of falls: rate of inpatient falls per 1,000 patient days.
Acute care prevention of falls: rate of inpatient falls with injury per 1,000 patient days.
Adult low back pain: percentage of patients with a diagnosis of back pain for whom the physician ordered imaging studies during the six weeks after pain onset, in the absence of "red flag."
Assessment and management of chronic pain: percentage of patients diagnosed with chronic pain who are prescribed an opioid who have an opioid agreement form and urine toxicology screen documented in the medical record. [NQMC Update Pending]
Atrial fibrillation: percentage of patients (without contraindications to anticoagulation) with paroxysmal, persistent, or permanent atrial fibrillation/flutter with risk factors for thromboembolism who are taking warfarin.
Atrial fibrillation: percentage of patients with non-valvular atrial fibrillation/flutter with risk factors for thromboembolism having a CHADS2 score of 2 or greater (without contraindications to anticoagulation therapy) who are receiving warfarin.
Colorectal cancer screening: percentage of African American patients age 45 and older who are up-to-date with colorectal cancer screening.
Colorectal cancer screening: percentage of patients age 50 and older who are up-to-date with colorectal cancer screening.
Diagnosis and initial treatment of ischemic stroke: percentage of patients who were screened for dysphagia before taking any food, fluids or medication (including aspirin) by mouth.
Diagnosis and management of asthma: percentage of adults with uncontrolled asthma who are on inhaled corticosteroids medication.
Diagnosis and management of asthma: percentage of children with uncontrolled asthma who are on inhaled corticosteroids medication.
Diagnosis and management of asthma: percentage of patients with asthma with education about asthma documented in the medical record.
Diagnosis and management of asthma: percentage of patients with asthma with spirometry or peak flow meter reading documented in the medical record at the last visit.
Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients diagnosed with ADHD whose medical record contains documentation that the clinician discussed the need for school-based supports and educational service options for children with ADHD.
Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients newly diagnosed with ADHD whose medical record contains documentation of DSM-IV or DSM-PC criteria being addressed.
Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients treated with medication for the diagnosis of ADHD whose medical record contains documentation of a follow-up visit twice a year.
Diagnosis and management of chronic obstructive pulmonary disease (COPD): percentage of patients with COPD whose physician inquired about smoking cessation (if patient a smoker) at every visit.
Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with acute myocardial infarction (AMI) receiving beta-blockers within 24 hours of arrival and on discharge. [NQMC Update Pending]
Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with acute myocardial infarction (AMI) receiving thrombolytics with a "door-to-drug time" (time from presentation to administration of drug) of less than 30 minutes. [NQMC Update Pending]
Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with chest pain symptoms in the emergency department receiving early therapy including intravenous access, oxygen, nitroglycerin, morphine and a chewable aspirin on arrival. [NQMC Update Pending]
Diagnosis and treatment of headache: percentage migraineurs with treatment plans for mild, moderate, and severe headaches.
Diagnosis and treatment of headache: percentage of migraineurs who have documentation in the medical record that they have received written educational materials on migraines at a clinic/office visit.
Diagnosis and treatment of otitis media in children: percentage of caregivers receiving education on the symptoms suggestive of otitis media, appropriate indicators for a provider visit, risk factors, and outcomes of otitis media.
Diagnosis and treatment of otitis media in children: percentage of patients with a diagnosis of acute otitis media who were prescribed amoxicillin.
Diagnosis and treatment of respiratory illness in children and adults: percentage of encounters for cold symptoms (phone care and/or office visits) for which there is documentation of home treatment education.
Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with a diagnosis of pharyngitis who had strep screen testing.
Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with an office visit for cold symptoms who have had symptoms for less than seven days and who receive an antibiotic.
Diagnosis of breast disease: percentage of class 4 or class 5 abnormal mammograms that are followed by a biopsy within 7 to 10 days. [NQMC Update Pending]
Foreign object retention: percentage of unintentionally retained foreign objects during labor and delivery. [NQMC Update Pending]
Heart failure in adults: percentage of adult heart failure patients to whom (or to their caregivers) written or verbal instructions or educational material are given during the clinic visit, addressing one or more of the following: activity level, diet, medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen (primary care and outpatient cardiology). [NQMC Update Pending]
Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and met the following (for which they are eligible) at their last clinic visit: prescribed or were taking ACEI/ARB, prescribed or were on beta blocker therapy, non-smoker (primary care and outpatient cardiology). [NQMC Update Pending]
Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and were prescribed or were on beta-blocker therapy within the last 12 months of the clinic visit or who have a contraindication to taking beta-blockers (primary care and outpatient cardiology). [NQMC Update Pending]
Heart failure in adults: percentage of adult heart failure patients who have ever had LVSD and were prescribed or were taking an ACEI or ARB within the last 12 months of the clinic visit, or who have contradictions to taking both ACEI or an ARB (primary care and outpatient cardiology). [NQMC Update Pending]
Heart failure in adults: percentage of adult heart failure patients who have not used tobacco anytime during the previous year (primary care and outpatient cardiology). [NQMC Update Pending]
Heart failure in adults: percentage of adult heart failure patients who have used tobacco anytime during the previous year and who were given smoking cessation advice or counseling at the last clinic visit (primary care and outpatient cardiology). [NQMC Update Pending]
Heart failure in adults: percentage of adult heart failure patients with documentation that LVS function was evaluated or will be evaluated (primary care and outpatient cardiology). [NQMC Update Pending]
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure discharged home with written instructions or educational material given to the patient or his or her caregiver at discharge or during the hospital stay, addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. [NQMC Update Pending]
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who are readmitted for heart failure within 30 days of discharge. [NQMC Update Pending]
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have LVSD and who do not have a contraindication to taking beta-blockers, who are prescribed beta-blocker therapy at hospital discharge. [NQMC Update Pending]
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have LVSD and who do not have contraindications to taking both ACEI and ARBs, who are prescribed an ACEI or an ARB at hospital discharge. [NQMC Update Pending]
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have used tobacco anytime during the year prior to hospital arrival and who are given smoking cessation advice or counseling during the hospital stay or at discharge. [NQMC Update Pending]
Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. [NQMC Update Pending]
Hypertension diagnosis and treatment: percentage of adult patients who have blood pressure less than 140/90 mmHg at their clinic visit.
Hypertension diagnosis and treatment: percentage of adult patients with hypertension, presenting in clinic within the last month, for whom patient education about modifiable risk factors has been documented in the medical record.
Immunizations: percentage of adolescents who are on time with recommended immunizations (Hep B, Hep A, HPV, MMR, MCV4, Tdap, VZV). [NQMC Update Pending]
Immunizations: percentage of two-year-old patients who are on time with their primary series of immunizations (DTaP, IPV, MMR/MMRV, PCV7/PPV23, VZV, Hib, Hep B, Hep A, Rota, Influenza). [NQMC Update Pending]
Initial management of abnormal cervical cytology (Pap smear) and human papillomavirus (HPV) testing: percentage of adult women diagnosed with initial abnormal cervical cytology of atypical squamous cells of undetermined significance (ASCUS) with high-risk HPV type who have follow-up colposcopy within six months of abnormality identified.
Lipid management in adults: percentage of patients on a lipid lowering medication who have a fasting lipid panel every 3 to 12 months. [NQMC Update Pending]
Lipid management in adults: percentage of patients with diagnosed coronary heart disease (CHD) or CHD equivalent who have had a diet evaluation. [NQMC Update Pending]
Major depression in adults in primary care: percentage of patients who commit suicide at any time while under depression management with a primary care physician.
Major depression in adults in primary care: percentage of patients who have a depression follow-up contact within three months of initiating treatment.
Major depression in adults in primary care: percentage of patients who have had a response to treatment at six months (+/- 30 days) after initiating treatment, e.g., have had a Patient Health Questionnaire (PHQ-9) score decreased by 50% from initial score at six months (+/- 30 days).
Major depression in adults in primary care: percentage of patients who have reached remission at six months (+/- 30 days) after initiating treatment, e.g., have any PHQ-9 score less than five after six months (+/- 30 days).
Major depression in adults in primary care: percentage of patients whose symptoms are reassessed by the use of a quantitative symptom assessment tool (such as Patient Health Questionnaire [PHQ-9]) within three months of initiating treatment.
Major depression in adults in primary care: percentage of patients with a new diagnosis of major depression, with documentation of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR) criteria within the three months prior to initial diagnosis.
Major depression in adults in primary care: percentage of patients with diabetes with documentation of screening for depression.
Management of labor: percentage of births with amnioinfusion when either of the following is present: thick meconium or repetitive severe variable decelerations or oligohydramnios.
Management of labor: percentage of women in the guideline population who have spontaneous rupture of membranes (SROM) or early amniotomy.
Management of labor: percentage of women in the guideline
